Form Seguro de Saúde

Health Insurance Reimbursement Request

Health Card No. MCS

Policyholder

1. PARTICIPANT’S STATUS

Select

Name

Phone

2. IDENTIFICATION OF THE INSURED PERSON

Name

Address

Phone

Email

3. EXPENSES – SELECT ONE OPTION

CurrencyMZNUSD€

Hospitalization

Hospitalization Amount

Consultations

4. TYPE OF EXPENSES

Exams

Treatments

Medicines

Orthotics

Prosthetics

Stomatology

Others

5. ATTACH SUPPORTING DOCUMENTS

Examinations, Prostheses, Medications – Submit the Medical Prescription.
Treatments – Medical Prescription together with the Medical Report regarding the diagnosis of the clinical condition and its progress.
Hospitalization (Childbirth, Accident or Illness) – Submission of the hospitalization receipt with a breakdown of all expenses, as well as the Medical Report.
Dental treatment form (Stomatology) – Receipt accompanied by the treatment form, which must contain details of the treatments performed as well as the identification of the treated teeth.

Note: The doctor’s name, specialty, address, and the establishment’s registration/tax ID must be clearly legible.

Documents

No file chosen

Attach all original documents/receipts/invoices/proof of payment, medical report, prescription, bank details, or any other documents that prove or justify the need for the reimbursement request.

6. REMARKS / REASONS

7. DECLARATION

The information provided is accurate, truthful, and given in good faith, and I take full responsibility for it.I authorize the Insurer to collect additional personal data from public entities, specialized companies, and other economic units, in order to confirm or complement the collected elements necessary for managing the contractual relationship. The client is responsible for any omissions, inaccuracies, or false information provided. Access to the provided personal data will be strictly confidential, provided that it is compatible with the purpose of its collection.