MEDICAL AID CLAIM FORM Claim Number:{{$invoice->claim_id}}
MEDICAL AID SOCIETY: {{$invoice->coPayer->name}}
MEMBER's NAME: {{$invoice->patientCoPayer->member_name}}
CONTACT TEL. NO: {{$invoice->patient->tel}} ID NO: {{$invoice->patient->id_number}}
CELLPHONE NO: {{$invoice->patient->mobile}} E-MAIL: {{$invoice->patient->email}}
POSTAL ADDRESS: {!! $invoice->patient->address !!} @if(!empty($invoice->patient->city)) {{$invoice->patient->city}} @endif @if(!empty($invoice->patient->state)) {{$invoice->patient->state}} @endif @if(!empty($invoice->patient->country)) {{$invoice->patient->country->name}} @endif
NAME OF EMPLOYER/GOVT DEPT: {{$invoice->patient->employer_name}}
PATIENT's NAME RELATIONSHIP
TO MEMBER		 MEMBER's
NUMBER		 PATIENT's
SUFFIX No.		 PATIENT's
DATE OF BIRTH		 B/P
O/R		 STAFF
{{$invoice->patient->name}} @if(!empty($invoice->patientCoPayer->patientRelationship)) {{$invoice->patientCoPayer->patientRelationship->name}} @endif {{$invoice->patientCoPayer->membership_number}} {{$invoice->patientCoPayer->suffix}} {{$invoice->patient->dob}}

SIGNATURE - BEFORE SIGNING, PLEASE NOTE

1. IF YOU SIGN THIS CLAIM FORM FOR ANY TREATMENT WHICH HAS NOT BEEN PROVIDED YOU MAY WELL BE COMMITTING AN OFFENCE. IF YOU BECOME AWARE THAT THE CLAIM IS SUBMITTED FOR SERVICES WHICH HAVE NOT BEEN PROVIDED YOU MUST CONTACT YOUR MEDICAL AID SOCIETY FORTHWITH.

2. IF THIS TREATMENT HAS NOT BEEN PAID FOR THEN YOU MUST EITHER SIGN EACH DAY THE TREATMENT IS RECEIVED OR ONCE ONLY AFTER THE PROVIDER OF SERVICES HAS INSERTED ALL HIS CHARGES.

NB: - CLAIM FORMS WHICH ARE SIGNED BEFORE THE DAY ON WHICH THE TREATMENT IS TO BE RECEIVED WILL BE REJECTED.

3. IF THIS TREATMENT HAS BEEN PAID FOR, YOU SHOULD SIGN THE FORM ONCE ONLY BEFORE SENDING IT TO YOUR MEDICAL AID Society. ATTACH YOUR RECEIPT AND INSERT THE AMOUNT YOU ARE CLAIMING IN THE APPROPRIATE BOX ALONGSIDE YOUR SIGNATURE.
SIGNATURE DATE RELATIONSHIP
TO MEMBER		 FEE CHARGED
(IF KNOWN)

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 DEPENDENT OF THE MEDICAL AID SOCIETY SHOWN ABOVE. I AUTHORISE THE PROVIDER OF SERVICES TO DISCLOSE THE NATURE OF ILLNESS TO THE MEDICAL AID SOCIETY 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.
FOR COMPLETION BY PROVIDER OF SERVICES
AHFoZ PAYEE No DATE CLAIM CLOSED ACCOUNT REF No.
{{date("Y-m-d")}} {{$invoice->id}} FOR USE BY MEDICAL AID SOCIETIES
RELEVANT AHFoZ NOs:
NAME OF REFERRING PRACTITIONER (IF ANY):
B/P
O/R		 STAFF
NAME OF REFERRING PRACTITIONER (IF ANY):
NAME OF SURGICAL ASSISTANT (IF ANY):
LINE TARIFF No. Mod 1 Mod 2 QTY YR MTH DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 FEE CHARGED AWARD PERSONAL A/C SHORTFALL REASON B/P
O/R		 STAFF

GROSS AMOUNT CLAIMED:{{number_format($invoice->co_payer_amount,2)}}

I hereby certify that, I, or members of my staff, have rendered the above services to or on behalf of the person. I confirm that to the best of my knowledge the patient treated is the patient named on this form. I agree that any claim for services not provided would be regarded as fraudulent and render the person concerned liable for prosecution.

DIAGNOSIS:

_________________________________________________

SIGNATURE & OFFICIAL STAMP OF PROVIDER OF SERVICES

DATE:{{date("Y-m-d")}}