Van Breda Claim Form
Group medical, hospital and dental Scheme Claim for reimbursementof expenses Van Breda Claim Form
5.00.185invc (1010) Vanbreda International • P.O. Box 69 • 2140 Antwerpen • Belgium NV • RPR Antwerpen • VAT BE 0414 783 183 • BFIC 13799 A-R Provider claim form for direct payment of outpatient medical services Please read the instructions on the reverse side.
How to fill out the claim form •Write your name in the same way as printed on your Vanbreda ID card on all claims. •Clearly mention your Vanbreda insurance number on each claim form.
In case you opt for a bank transfer in USD, please provide your complete banking details on the GGIPC Medical Claim Form. 1.3 Payments are made by check or bank transfer in USD. 2.
per claim form will be allowed and that if no reimbursement currency is selected on the claim form or if data are insufficient to provide the payment selected,
In the case of a patient covered under Van Breda, the staff member must complete and send directly to Van Breda's Claim Department (fax 32-3-2367538), ... The attending physician may be requested to give support in completing the Van Breda Cost Estimate Form.
BUB March 2009 4 You can submit claims for reimbursement of medical, hospital and dental expenses by means of the attached claim form. You can fill it out and send it to: ...
... or to found any claim upon his own iniquity or to acquire ... With the collapse of Roman rule in AD 476 the reception of Roman law took a new form which involved resorting to Roman law ... A good illustration of the use of custom as a source of law is the case of Van Breda v Jacobs ...
In UNAMID/MINURCAT the PAS was a problem because activities had been inherited form UNMIS; ... medical claims the Council agreed that the FSU needs to pursue continued reimbursement of the 20% not covered by Van Breda insurance by F10 claim or other option, ...
Please note that only one currency per claim form will be allowed and that if no reimbursement currency is selected on the claim form or data are insufficient to provide the payment selected, ...
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