PakQatarFamilyTakafulLimited

HeadOffice:SuiteNo.203205,BusinessArcade,P.E.C.H.S.,Block6,
MainShareaFaisal,Karachi,Pakistan
TelNo.(9221)438035761.FaxNo.:(9221)4386451

Part HospitalizationReimbursementClaimForm

B ;
;
TobecompletedbytheTreatingPhysician.
Donotleaveanyblank,unansweredquestions,datesorsignatures,whereverapplicable.

PatientsName:

PatientFathers/HusbandsName: Sex: Male Female

DateofBirth: CNIC Number:

1. Howlonghaveyoubeenthepatients doctor?
2. Onwhatdatewereyoufirstconsultedfortheinjury,illnessormedical
conditionconcernedorforanyrelatedcondition?

3. Pleasegiveyourdiagnosisoftheinjury/illness/condition?

4. Haveyouanyreasontobelievethatthesameoranyrelatedconditionhas
beendiagnosedortreatedpreviouslybyanyotherdoctororhospital?

5. Hasthepatientconsultedanydoctorfortheabovementionedmedicalcondition? Yes No
IfYes,foreachdoctorandhospitalconsulted,statename,address,andtreatmentprovided.
NameofDoctor/Hospital DateofConsultation ReasonforConsultation Treatment/Results

6. Pleasegivedetailsofthetreatmentgivenor
prescribed?

1. DurationofPregnancy? 1stTrimester nd
2 Trimester
rd
3 Trimester weeks

ForMaternityclaimonly

2. Wouldnormaldeliveryendangerforthelifeofmotherand/orchild(ren)andintra
abdominalsurgerynecessaryforextrauterinepregnancyorcomplications? Yes No
IfYes,pleasegivereasonindetail:

3. Isthereanyperniciousvomitinginpregnancy,toxemiawithconvulsionsor
spontaneousabortion? Yes No
IfYes,pleasegivereasonindetail:

DECLARATION
Iherebycertifythatallanswerstoquestionsappearingonthisformaretrueandcompletetothebestofmyknowledgeandbelief.

DateofStatement:
Signatureoftreatingphysician

NameofPhysician PMDCNo.:

Address: ContactNo.:

Pleaseensurethat:
; UseaNewClaimFormforeachclaimorcourseoftreatment.
; TheIndividualCoveredorhis/herlegalrepresentativesmustcompleteallquestionsofPartAoftheclaim
formandsignit.
; ThetreatingphysicianmustcompleteallquestionsofPartBoftheclaimformandsignit.
; Pleaserecheckandsendfullycompletedclaimformwithallrelevantdocument(s)/ReportstoPakQatar

FamilyTakafulLimited.
; Pleasebeinformedthat;
o IncompleteclaimformCANNOTbeacceptedforprocessingofpayment.
o InsuretoattachORIGINALSofallrelevantdocument(s)/Report.
o InsuretoattachORIGINALbillsandreceiptsofpayment(s).
o PHOTOCOPIESarenotacceptableforprocessingaclaim.

RefNo.GH/CL/2008/00039/1