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Claims Students Signature


Claim Submission

Any person who knowingly files a statement of claim containing any misrepresentation or any false,
incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.

The above answers are true and correct to the best of my knowledge.
I authorize any physician, medical institution, pharmacy, insurance company, employer, labor union, or association to release information to dhig Gmbh, KOOPERATIVA poisťovňa, a. s. Vienna Insurance Group, to Europ Assistance CIS and to Global Assist, as required to properly pay all benefits, if any due to me, my spouse, or any other dependents.
A photocopy of this authorization shall be considered effective and valid as the original.

 

Consent:



Personal Information:





Insurance Information:







 

Details of the claim:













Hospital & Physician information:




 

Bills / Receipts:







 

Reimbursment:









 

Leave this empty:

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Signature Certificate
Document name: Claims Students Signature
lock iconUnique Document ID: 6982629fe413beece33e5160794e0fa4972c22de
Timestamp Audit
11/02/2021 11:26 CETClaims Students Signature Uploaded by daily health insurance group dhig - contact@dhig.net IP 10.80.0.109
11/02/2021 11:29 CETdail health claims - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.172
30/08/2021 12:32 CETdaily health claims - claims@dhig.net added by daily health insurance group dhig - contact@dhig.net as a CC'd Recipient Ip: 10.80.0.109