Free Medical Reimbursement Checklist Template
Medical Reimbursement Checklist
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Name |
Company |
Address |
|
[your name] |
[your company name] |
[your company address] |
This checklist ensures that all necessary information and documentation for a medical reimbursement claim are submitted correctly. The professional layout facilitates an efficient and systematic process for both claimants and office personnel.
Supporting Documents:
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YES |
NO |
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Medical Reports. |
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Doctor's Note. |
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Pharmacy Bills. |
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Documentation for Reimbursement:
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YES |
NO |
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Attach Medical Reports. |
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Include Doctor's Prescription Note. |
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Pharmacy Receipts and Bills. |
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Submission Protocol
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YES |
NO |
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Complete, verify, and sign the claim form. |
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Attach a detailed breakdown of treatment costs. |
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Ensure all supporting documents are attached. |
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Submit the completed form to the insurance provider. |
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Conduct follow-ups to track the claim status. |
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Professional Verification
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YES |
NO |
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Patient's dependency on claimant verified. |
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Essential Certification/AE form completed and countersigned. |
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Discharge Certificate/Summary for inpatient treatment attached. |
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Laboratory/Investigation and consultation fee breakdown provided. |
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Special Nursing Certificate attached, if applicable. |
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Office Use Only
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YES |
NO |
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Claim submitted within the stipulated 90-day period post-treatment. |
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Detailed medication list provided in block capitals. |
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Verification of claim form and documents for accuracy and completeness. |
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Claimant's Signature: __________________________ Date: ___________
Office Representative's Signature: ______________ Date: ___________
