IFRC

1IFRC
2Costs informations
3Nature of medical cost
4Obligatoirement des factures
5You have almost completed the form

IFRC

Who are you?

Relationship

Title

Please use your business email address (@ifrc.org)

Patient informations:

Title

Date of birth (date/month/year)

Costs informations

Does the invoice(s) relate to a hospitalization?

Admission date

Discharge date

Does this claim relate to an accident?

In case of injury claim, please contact Miss Francine Golay or your HR Department

Nature of medical cost

If your claim form contains invoices from different years it will be refused!
Do not add up invoices in one line "Nature of medical cost" needs to be precise invoices more than one year old (invoice date) will not be reimbursed

Please attach copies of invoices and medical prescriptions related to this claims (scanned PDF File only). The original documents must be stored 1 year in case of control of the insurance.

Number of invoices

Invoice 1

Nature of medical cost

Nature of medical treatment

Invoice 2

Nature of medical cost

Nature of medical treatment

Invoice 3

Nature of medical cost

Nature of medical treatment

Invoice 4

Nature of medical cost

Nature of medical treatment

Invoice 5

Nature of medical cost

Nature of medical treatment

Invoice 6

Nature of medical cost

Nature of medical treatment

Invoice 7

Nature of medical cost

Nature of medical treatment

Invoice 8

Nature of medical cost

Nature of medical treatment

Invoice 9

Nature of medical cost

Nature of medical treatment

Invoice 10

Nature of medical cost

Nature of medical treatment

Invoice 11

Nature of medical cost

Nature of medical treatment

Invoice 12

Nature of medical cost

Nature of medical treatment

Obligatoirement des factures

Would you like to attach documents?

You have almost completed the form

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