Reimbursement Form

Terms and Condition

You may refer to the reimbursement section of our user manual before completing this form
Please note that your claim will only be processed, if your claim is approved by the Quality Assurance Team after due diligence and proper investigation.
Authenticated claims which comply to the terms and conditions of treatment within the benefit cover of the client would be vetted with our generic (operational) tariff and paid within 30 working days of our receiving the completed application.
Your claims may be declined if due process was not followed.
You may delay or forfeit a reimbursement by either not giving proper information; non compliance with ROHL modus operandi; going beyond the package benefit cover or not informing ROHL within 48 hours for proper and prompt verification by the Quality Assurance department.
Please complete the client section of this form in order to be assured of processing within 30 working days.
All the fields under the client section are compulsory.
Submission of duplicate and scanned copies of applicable documents as opposed to original copies may delay payment.
Incomplete forms will not be processed.
You may be asked to present more documents apart from the ones submitted in order to verify your request.
A medical report must accompany all cases of surgery , admission, procedures and special /advanced investigations
We may seek for part reimbursement from other packages or plans you are registered under; which covers same benefits you are requesting payment for after due settlement.
We may seek for part reimbursement from other packages or plans you are registered under; which covers same benefits you are requesting payment for after due settlement.
It is a crime to request for a reimbursement with the intent to defraud any individual or organization.Any information or material fact concealed or altered with the intent to mislead us may be reported to your Human Resource Department(if applicable) or other appropriate authorities if uncovered.
The form must be fully completed and signed. Roding Healthcare will not take responsibility for non payment of claims due to incomplete information and/or documentation.
If the applicant is under 18 years of age this declaration must be signed by their parent or legal guardian.

  • NAME OF ATTACHED DOCUMENT(S) IN SUPPORT OF THE REIMBURSEMENT

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