Cleaning Services Medical Claim Submission Form
Cleaning Services Medical Claim Submission Form
Please complete this form with accurate and detailed information regarding the medical claim related to cleaning services. Attach all relevant receipts and documentation to support your claim and submit it to the HR Department or the designated claim officer.
Employee Information
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Full Name: |
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Employee ID: |
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Department: |
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Position: |
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Contact Number: |
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Email Address: |
Incident Details
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Date of Incident: |
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Location of Incident: |
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Brief Description of Incident: |
Medical Information
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Type of Injury/Illness: |
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Date of First Medical Consultation: |
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Name of Medical Facility: |
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Name of Attending Physician: |
Medical Expenses
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Expense Type |
Amount |
Receipt Attached (Yes/No) |
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Consultation Fees |
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Medication |
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Diagnostic Tests |
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Treatment/Procedure |
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Total |
Declaration and Authorization
I hereby declare that the information provided above is accurate and complete to the best of my knowledge. I understand that any misrepresentation of facts may lead to the denial of my claim or disciplinary action by [Your Company Name]. I authorize [Your Company Name] and its designated insurance provider to review and process my claim based on the information provided herein.
[Date]
