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CHISF01 Claim for Reimbursement of Medical Expenses  Form

CHISF01 Claim for Reimbursement of Medical Expenses Form

Use a CHISF01 Claim For Reimbursement Of Medical Expenses template to make your document workflow more streamlined.

His/her representative hereby confirm that I subrogate UNIQA GlobalCare S.A. I take note that I may not conclude an agreement with the responsible third party regarding medical expenses covered by this subrogation. I authorise UNIQA GlobalCare S.A. Town Postcode Country Telephone e-mail Other insurance covering the patient Are the medical expenses associated with this accident covered by other insurance e.g. other primary health insurance sport licence etc. yes Name of the insurance Policy...
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