Raport medical model 2026

1. Click ‘Get Form’ to open the raport medical model in the editor.
2. Begin by entering the name of the insurer, ALLIANZ - ȚIRIAC ASIGURĂRI S.A., in the designated field.
3. Fill in the medical institution's name and address. Ensure accuracy for proper documentation.
4. Input the insured person's full name and personal identification number (Cod numeric personal) as per their ID document.
5. Provide a contact number for the insured, followed by their insurance card number.
6. Detail the health status of the insured, including current symptoms and medical history.
7. Specify any presumptive or definitive diagnoses along with corresponding ICD 10 codes.
8. Document information regarding the cause and stage of the primary medical condition, selecting from options like acute illness or chronic condition.
9. List all medical services performed, including dates, and recommend any further services needed.
10. Ensure both patient and physician sign and stamp the report to validate it before submission.

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