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BLUE Healthcare that works where you work www. libertyheathblue. com BLUE INVOICE NUMBER MEDICAL CLAIM FORM THIS FORM MUST BE COMPLETED FOR EVERY PATIENT RECEIVING TREATMENT. PLEASE COMPLETE A SEPERATE CLAIM FORM FOR EACH VISIT AND ATTACH YOUR INVOICE FOR PROCESSING. THE PATIENT SHOULD BE GIVEN A DUPLICATE COPY FOR THEIR RECORDS. PLEASE ATTACH DETAILED INVOICE WHERE POSSIBLE TO EXPEDITE PAYMENT. PLEASE COMPLETE FORM IN BLOCK LETTERS. IMPORTANT THE HERITAGE INSURANCE COMPANY KENYA WILL REJECT ILLEGIBLE OR INCOMPLETE CLAIMS PATIENT DETAILS FIRST NAME MEMBER NO SURNAME DEP. CODE GENDER M DOB. F D M Y MAIN MEMBER DETAILS EMPLOYER SERVICE PROVIDER DETAILS NAME OF CLINIC LIBERTY HEALTH PROVIDER NO CONSULTING PHYSICIAN TREATMENT DATE SHOULD HOSPITALISATION HAVE BEEN REQUIRED PLEASE INDICATE DURATION OF STAY ADMISSION DATE DISCHARGE DATE CODE TICK DIAGNOSIS ALLERGIC RHINITIS J30 C-SECTION O82 MALARIA B54 PHARYNGITIS J02 ANAEMIA D64 DENTAL CARIES K02 MYOPIA H52 PNEUMONIA J18 ANTENATAL SCREENING Z36 DERMATITIS L30 SPONTANEOUS BIRTH O80 BRONCHITIS J40 DIARRHOEA/GASTRO TONSILLITIS J03 CANDIDIASIS B37 CONJUNCTIVITIS DIAGNOSIS CODING H10 A09 OPTICAL EXAMINATION OF EYES AND VISIONI Z01 GASTRITIS K29 OTITUS MEDIA H66 URTI J06 INFLUENZA J10 PEPTIC ULCER K27 N39 Other CONSULTATION 0190 - GP IS THIS A MATERNITY RELATED CLAIM CODE 0191 - SPECIALIST Yes 11001 - OPTICAL 8101 - DENTAL OTHER COST No DESCRIPTION LABORATORY TESTS OTHER DIAGNOSTIC PROCEDURES / TESTS OPTICAL DENTAL QTY DOSAGE PRESCRIBED DRUGS ATTACH COPY OF PRESCRIPTION PROVIDER S DECLARATION I CERTIFY THAT THE ABOVE PATIENT HAS RECEIVED THE SERVICES TREATMENT NOTED ON THIS FORM DIAGNOSED AND ADMINISTERED BY MYSELF AND THAT THIS CLAIM IS IN ACCORDANCE WITH MY SPECIFIED TREATMENT SIGNED DATE PROVIDER STAMP PATIENTS DECLARATION I HEREBY DECLARE THE ABOVE STATED TO BE TRUE AND IN ACCORDANCE WITH THE MEDICAL SCHEME RULES. I CONFIRM THAT THE DETAILS GIVEN ABOVE ARE CORRECT THAT THE AMOUNT CLAIMED HEREIN IS NOT CLAIMABLE FROM ANOTHER SOURCE AND THAT THE PATIENT IS A MEMBER OR DEPENDANT ON BLUE HEALTH INSURANCE. I AUTHORISE THE PROVIDER OF SERVICES TO DISCLOSE THE NATURE OF ILLNESS TO BLUE FOR ITS CONFIDENTIAL USE AND I AGREE THAT NO AWARDS WILL BE MADE FOR THIS TREATMENT UNLESS CONTRIBUTIONS ARE RECEIVED IN RESPECT OF THE PERIOD OF TREATMENT. LIBERTY HEALTH RESERVES THE RIGHT TO RECOVER ANY AMOUNTS PAID TO PROVIDERS IN EXCESS OF BENEFITS DIRECTLY DATE The Heritage Insurance Company Kenya Limited CfC House Mamlaka Road P. PLEASE COMPLETE FORM IN BLOCK LETTERS. IMPORTANT THE HERITAGE INSURANCE COMPANY KENYA WILL REJECT ILLEGIBLE OR INCOMPLETE CLAIMS PATIENT DETAILS FIRST NAME MEMBER NO SURNAME DEP. CODE GENDER M DOB. F D M Y MAIN MEMBER DETAILS EMPLOYER SERVICE PROVIDER DETAILS NAME OF CLINIC LIBERTY HEALTH PROVIDER NO CONSULTING PHYSICIAN TREATMENT DATE SHOULD HOSPITALISATION HAVE BEEN REQUIRED PLEASE INDICATE DURATION OF STAY ADMISSION DATE DISCHARGE DATE CODE TICK DIAGNOSIS ALLERGIC RHINITIS J30 C-SECTION O82 MALARIA B54 PHARYNGITIS J02 ANAEMIA D64 DENTAL CARIES K02 MYOPIA H52 PNEUMONIA J18 ANTENATAL SCREENING Z36 DERMATITIS L30 SPONTANEOUS BIRTH O80 BRONCHITIS J40 DIARRHOEA/GASTRO TONSILLITIS J03 CANDIDIASIS B37 CONJUNCTIVITIS DIAGNOSIS CODING H10 A09 OPTICAL EXAMINATION OF EYES AND VISIONI Z01 GASTRITIS K29 OTITUS MEDIA H66 URTI J06 INFLUENZA J10 PEPTIC ULCER K27 N39 Other CONSULTATION 0190 - GP IS THIS A MATERNITY RELATED CLAIM CODE 0191 - SPECIALIST Yes 11001 - OPTICAL 8101 - DENTAL OTHER COST No DESCRIPTION LABORATORY TESTS OTHER DIAGNOSTIC PROCEDURES / TESTS OPTICAL DENTAL QTY DOSAGE PRESCRIBED DRUGS ATTACH COPY OF PRESCRIPTION PROVIDER S DECLARATION I CERTIFY THAT THE ABOVE PATIENT HAS RECEIVED THE SERVICES TREATMENT NOTED ON THIS FORM DIAGNOSED AND ADMINISTERED BY MYSELF AND THAT THIS CLAIM IS IN ACCORDANCE WITH MY SPECIFIED TREATMENT SIGNED DATE PROVIDER STAMP PATIENTS DECLARATION I HEREBY DECLARE THE ABOVE STATED TO BE TRUE AND IN ACCORDANCE WITH THE MEDICAL SCHEME RULES. I CONFIRM THAT THE DETAILS GIVEN ABOVE ARE CORRECT THAT THE AMOUNT CLAIMED HEREIN IS NOT CLAIMABLE FROM ANOTHER SOURCE AND THAT THE PATIENT IS A MEMBER OR DEPENDANT ON BLUE HEALTH INSURANCE. I AUTHORISE THE PROVIDER OF SERVICES TO DISCLOSE THE NATURE OF ILLNESS TO BLUE FOR ITS CONFIDENTIAL USE AND I AGREE THAT NO AWARDS WILL BE MADE FOR THIS TREATMENT UNLESS CONTRIBUTIONS ARE RECEIVED IN RESPECT OF THE PERIOD OF TREATMENT.