Formulir Klaim Jasindo Health [PDF]

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JASINDO HEALTH CARE Menara MTH Lt. 15 Suite 1502-1505 Jl. Letjen MT Haryono Kav. 23 Jakarta 12820 Telp. (021) 83782490, Fax. (021) 8378 2460 http:///www.jasindo.co.id Call Centre Swipe Card 24 Jam : Telp +62 21 2927 5151 Fax +62 21 351 0558



Call Centre Show Card 24 Jam : Telp +62 21 8378 2525 / 08118700022 Fax +62 21 8378 2485



FORMULIR KLAIM (CLAIM FORM) CASHLESS*



*Pilih sesuai kebutuhan



REIMBURSEMENT*



(Select as needed) 1 DATA PESERTA (Patient’s Information)) : ………………….........



Nama Karyawan (Employee’s Name) No. Peserta (Membership Number)



Nama Pasien (Patient’s Name) Nama Perusahaan (Company’s Name)



: ………………...............



Nama Pemilik Rekening : ……………………..…. (Account Owner Name)



Status pasien (Patient’s Status)



:



Pegawai (Employee’s)



: …………………….........…



Tanggal Lahir : …………………………... Jenis Kelamin : (date of birth) (Sex)



: ……………………….…..



No. Rekening : …………..…………...... (Account Number)



Pria (Male)



Wanita (Female)



No. Telpon Pemilik Rekening : ……………..…..… (Telephone Number Owner Account)



Suami/Istri (Husband/Wife)



Anak (Child) 2 INFORMASI PEMBERI PELAYANAN KESEHATAN (Service’s Information)



Rumah Sakit/ Klinik Dr. (Hospital/Clinic/dr Name) Tanggal Masuk (Date of Admission)



: …………………................…



Jenis Pelayanan Medis (Medical Services Type)



:



: ………………….......………...



Ruang Kelas (Room Class) Tanggal Keluar (Date of Discharge)



: ………………………............



Rawat Jalan (Outpatient); Rawat Inap (Hospitalization)



Jenis Kelamin: (Sex)



Pria (Male)



Wanita (Female)



: ………………………..........



[ ] Dr. Umum (General Practioner) [ ] Dr. Spesialis (Specialist) [ ] Dr. Gigi (Dentist) [ ] Sebelum dan Sesudah Rawat Inap (Pre/Post Hospitalization)



[ ] Kacamata (Spectacles)



RESUME MEDIS (Medical Resume) 1 Anamnesa (Anamnesis)



4



a) Keluhan Utama (Main Complaint) ……….............................................................................................................................................. ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... b) Keluhan Tambahan (Additional Complaint) ………............................................................................................................................................. ....................................................................................................................................................... .................................................................................................................................................... c) Sejak Kapan Peserta Mengalami Keluhan Tersebut (dated of complaint occur) .................................................................................................................................................... d) Riwayat Penyakit yang Diderita (History of illnes) ....................................................................................................................................................... ....................................................................................................................................................... 2 Pemeriksaan Fisik (Physical Examination) ……….............................................................................................................................................. ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ a) Tanda Vital (Vital Signs) : Kesadaran : CM/Delirium/Stupor/Coma *) GCS :................................................. (conscious : CM/Delirium/Stupor/Coma ) Tekanan Darah :.......................... Pernapasan : ....................................... (blood Pressure) (Respiration) Suhu Tubuh :......................... Nadi :........................................ (Body Temperature) (Pulse)



7 V



8



7 V



3



6 5 4 IV III



3 II



2



6 IV



3 II



2



5 4 III



1 I 1 I



Jenis Pembedahan (type of surgery)……….............................................................................. .................................................................................................................................................... …..…................................................................................................................................................ Hasil Lab / Diagnostik (Diagnostic/Laboratory Result) ..................................................................................................................................................... ..................................................................................................................................................... .................................................................................................................................................... …….............................................................................................................................................



6



7



Terapi dan Tindakan (Procedure/Medication) ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................



8



Anjuran atau Saran Pengobatan Selanjutnya (Medication Advice) ..................................................................................................................................................... ..................................................................................................................................................... .................................................................................................................................................... .....................................................................................................................................................



9 Diagnosa Medis Berhubungan dengan (beri tanda [v]) (is the diagnosis related to, give a [v] check list)



b) Pemeriksaan Gigi (Dental Examination) 8



5



Diagnosa Tambahan jika ada (Additional Diagnosis, if any) .................................................................................................................................................... .................................................................................................................................................... ................................................................................................................................................... .................................................................................................................................................... Pembedahan Jika ada (Surgery, if any)



1



2



4 5 6 III IV



7 V



8



I



3 II



12 I



3 II



4 5 6 III IV



7 V



8



◻ ◻ ◻ ◻



Kelainan Bawaan (congenital) Keturunan (Hereditary) Kosmetik (Cosmetic) Psikis/Psikomatis (Psychiatric/psychosomatic)



◻ Kesuburan (fertility/infertility) ◻ PHS (Sexual Trasmitted Desease) ◻ Kecelakaan Kerja/KKL (Accident) ◻ Lainnya (Others) :..........................



Diagnosa Kerja (Working Diagnosis) ………........................................................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................ ………..............................................................................................................................................



3 PERNYATAAN PESERTA (Authorization Statement) Dengan ini Saya memberi kuasa kepada Jasindo Healthcare untuk mendapatkan dan menyimpan segala keterangan/catatan medis (diagnosa, hasil pemeriksaan laboratorium & penunjang medis, perincian biaya, dll) dari klinik/Rumah Sakit atau pihak lain yang memberikan pelayanan medis kepada Saya sesuai ketentuan yang berlaku. Saya menyetujui bahwa biaya-biaya yang timbul sehubungan pelayanan kesehatan yang Saya terima akan diperhitungkan kemudian oleh Jasindo Health Care dimana dalam hal ini Saya akan bertanggung jawab atas biaya pelayanan dan/atau perlengkapan kesehatan yang tidak disantun dan/atau biaya yang melebihi batas santunan serta Saya tunduk pada ketentuan peraturan yang berlaku sehubungan dengan timbulnya biaya tersebut. I Hereby Authorize to Jasindo Heatlh Care to get my medical data or my medical record needed to analyze my claim from health provider/hospital/physician. And i also authorize to Jasindo Heatlh Care to inform the claim or medical care to my working place. If the medical care i have received is a part of employees health program benefit: and to insurance company, if the claims included in benefit that was covered by insurance policy. If the treatment cost over my benefit limit, i will pay the excess of the benefit. ……………., ………………………, 20….......



Tanda Tangan Pasien (Patient Signature)



---------------------------------(Nama Jelas Pasien) (Name of patient)



-----------------------------------------------------------------------( Nama Jelas, Tanda Tangan & Cap Stempel Dokter yang merawat) (Name, & Attending Physician signature)



Lampiran 1 untuk Jasindo Health Care, Lampiran 2 untuk Klinik/Rumah Sakit, Wajib Melampirkan  Formulir yang diisi lengkap oleh Peserta dan Dokter yang memeriksa atau merawat dengan disertai tanda tangan dan stempel dokter beserta alamat dan No. telp yang bisa dihubungi  Salinan Tes Hasil Lab dan Diagnostik (jika melakukan tes lab dan diagostik)  Salinan Resep obat  Kuitansi Pembayaran Asli dari RS/Klinik/Dokter/Apotik/Laboratorium  Perincian Biaya Perawatan (Khusus untuk Rawat Inap)



FORM KLAIM JASINDO HEALTH CARE 151015