Aon - Aia Ghs Claim Form - Oct 2014
Aon - Aia Ghs Claim Form - Oct 2014
Aon - Aia Ghs Claim Form - Oct 2014
CLAIM PROCEDURES
FOR PRIVATE HOSPITAL INPATIENT CLAIMS
Important Notes :
1. The claimant is required to submit the claims document within 20 days of discharge from the hospital.
2. To enable the claim to be processed on a timely basis, please duly complete all the questions in the claim form
and attach all the required documents.
3. The claim will be returned if the required documents are not provided together with this form.
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AIA SINGAPORE
GROUP HOSPITAL & SURGICAL CLAIM FORM
Corporate Solutions
3 Tampines Grande, #07-00, AIA Tampines, Singapore 528799, Fax: 6538 5603 / 6538 4340, Email : [email protected]
2) Name of Patient (if patient is dependant) NRIC / Passport No. Date of Birth (DD/MM/YY)
Date First Treated Date of Admission (DD/MM/YY) Date of Discharge (DD/MM/YY) Nature of Treatment / Operation Done
(DD/MM/YY)
2) Accident : Date (DD/MM/YY) & Time (HH/MM) Describe How Accident Happened & Nature of Injury
3) Are you claiming from other insurers? Yes No If yes, insurer’s name: Policy No.
Part C : Claims Payment Details (If is via GIRO, the bank details provided herein has to be Employee’s bank account)
Bank A/C
Bank Name Branch Code
No.
a) I/We hereby authorize, agree and consent to AIA Singapore to request from any hospital, physician, person or organization, all information
with respect to any illness, injury, medical history, and copies of all hospital or medical records concerning myself at any time and authorize the
prior mentioned organizations to disclose all such information to AIA Singapore.
b) I/We consent to AIA Singapore, its associated persons/organisations, third party service providers and representatives, whether within or
outside Singapore (collectively “AIA Persons”) to collect, use, disclose, store, retain and/or process (collectively, “Use”) all personal data and
information (“Personal Data”) provided to AIA Persons or that they possess about me/us, in the manner and for the purposes described in the
AIA Personal Data Policy (“PD Policy”) which is available on AIA Singapore’s website.
I/We agree to accept the provisions in the PD Policy as amended from time to time. Where Personal Data of another person is disclosed by
me/us, I/we confirm that I/we have obtained the consent of the individual concerned, except to the extent such consent is not required under
relevant laws to collect, use and/or disclose such Personal Data. I/We waive (on my/our own behalf and on behalf of each such other person)
any right to claim against any of the AIA Persons for any Use in the nature of or for the purposes described above or in the PD Policy. I/We will
indemnify AIA Persons for all losses and damages if I/we breach these provisions.
c) This consent shall bind my/our successors and assignees, and remains valid, notwithstanding death, irrespective of whether or not our
Application/form is accepted by AIA Singapore. A photocopy of this consent shall be valid and effective as the original.
2) Final Diagnosis of illness or extent of injury ICD Code ICD Code ICD Code
3) What is the cause of illness / injury? 4) Please specify the approximate date of discovery of the illness or
injury
5) How long has the illness / injury been existing prior to 6) Did the patient have any symptoms prior to consulting you?
consulting you? Yes No - If “Yes”, please indicate the nature of Symptoms and
date Symptoms first started:
7) When did the patient first consult you for this condition? 8) Nature and Date of Treatment rendered
9) Has the patient ever had the same or similar condition / symptom? Yes No Not to my knowledge
If "Yes", please indicate when and describe
10) Has the patient had any prior treatment for this condition? Yes No Not to my knowledge
If "Yes", please state the following :-
Name of Doctor First Consultation Date Name of Clinic Address
13) Date of surgical procedures or treatment rendered 14) If excision was performed, please indicate the size of the lesion /
tumor. Please attach a copy of the histology report.
16) Were the above surgical procedures approached through the 17) Was the surgery performed for cosmetic purposes?
same incision / orifice? Yes No Yes No
18) Is the condition / treatment related to : Yes If "Yes", please elaborate No
a) Congenital Anomaly / Genetic / Chromosomal Disorder a)
b) Psychological / Mental / Emotional Disorder b)
c) Dental / Gum Treatment / Oral Mucosal c)
d) Pregnancy / Childbirth / Infertility / Sub-fertility Condition d)
e) Self-inflicted Injury / Drug Addition / Alcoholism e)
19) Is the patient still under your care for this condition? Yes No - If "No" please give date service was terminated and furnished
name and address of doctor if the patient has been referred to another doctor for follow-up.
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