Claims notification - Medical

Medical Claim Notification

Submit your medical claim information online

At FPG Insurance, we’ve made it very easy for you to submit your medical claim online. Simply complete the following form and attach the relevant documents. We will then review your claim and if needed, a medical claim representative will contact you directly to confirm your claim details and request any additional information.

Basic Documents for Medical Insurance Claim

Download: Attending Physician's Result Form (to be filled and signed by attending physician)
Hospital statement of account with charge slips
Original Official Receipts of Hospital bill and Professional fees
Original Official Receipts of medicines purchased outside the hospital and their prescriptions (taken during confinement)
Admitting History Report
Discharge Summary

Need help with your claim? Call us at +632 944 1373 or email to jdelrosario@fpgins.com

Particulars of Claimant

Policy Number ^*

Patient's Name ^*

Address ^*

Insured's Name if Patient is a dependent

Certificate No.

If Group Insurance, name of Policyholder

Statement by Claimant (By Parent when claimant is a minor)

Date & Time Admitted

Date & Time Discharged

If as a result of an Accident, When did accident occur?

Give a brief description of circumtances

Was this accident reported to the Police? If so, give details

Upload Police Report Select Upload

Was another party responsible for the injury to yourself?

Yes

Are you covered for the whole or any of the above expenses by

Any Social Security System (SSS)?

Yes

Any other Medical or Accidental Insurance?

Yes

Any other Medical Benefits Scheme?

Yes

Upload Documents

Attending Physician's Result Form Select Upload

Hospital statement of account with charge slips Select Upload

Original Official Receipts of Hospital bill and Professional fees Select Upload

Original Official Receipts of medicines purchased outside the hospital and their prescriptions (taken during confinement) Select Upload

Admitting History Report Select Upload

Discharge Summary Select Upload

Declaration

I hereby authorize the undersigned physician and/ or hospital administrator to release any info rmation acquired in the course of my examination or treatment.

I, the undersigned, declare that the partic ulars stated on this form are true in every respect. I have supplied full information on all particulars relevant to this claim, and the amounts claimed herein are lawfully due to me under terms, conditions and exceptions of the above numbered policy.

Medical Claim Notification

Submit your medical claim information online

Particulars of Claimant

Statement by Claimant (By Parent when claimant is a minor)

Upload Documents

Declaration

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Medical Claim Notification

Submit your medical claim information online

Particulars of Claimant

Statement by Claimant (By Parent when claimant is a minor)

Upload Documents

Declaration

CORPORATE PRODUCTS

CLAIMS

ABOUT US

CONNECT WITH US