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Formulir klaim rawat inap

Klaim rawat form 2025

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The document is a Group Health Insurance Inpatient Claim Form that requires information about the patient, service details, and authorization for medical records. It includes sections for personal details, type of claim, relationship to employee, and a medical resume that must be filled out by a physician. Additionally, it outlines mandatory documents needed for claim submission.

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Click ‘Get Form’ to open the klaim rawat form in the editor.
Begin by filling in the 'Nama Perusahaan' (Name of Company) and 'Tanggal Pelayanan' (Date of Service) fields. Ensure accuracy as this information is crucial for processing your claim.
Next, enter the 'Nama Pasien' (Name of Patient) and 'Tempat Pelayanan' (Place of Service). These details help identify the patient and where services were rendered.
Fill in the 'No. Peserta Pasien' (No. of Patient Member) and select the appropriate 'Jenis Klaim' (Type of Claim), such as Rawat Inap (Inpatient).
Indicate the relationship of the patient to the employee by selecting from options like Self, Husband, Wife, or Child.
Provide a detailed note explaining the reason for reimbursement if applicable. This section is vital for claims involving cashless facilities.
Complete the Letter of Authority section by signing and dating it, allowing medical institutions to share necessary information regarding your claim.
Finally, ensure all required documents are attached before submitting your claim through our platform for a seamless experience.

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