Health Insurance Submission Form

The form below should be used to submit information and documents in order to submit a claim.
Providing all necesary documents to this submission form allows us to process your claim and your reimbursment as quickly as possible.

Primary policy holder information
Name*
First Last
Cedula or passport number*
Contact number*
Contact email*
Patient information
Name*
First Last
Cedula or passport number*
Patient's relationship to policy holder*
Age*
Upload all related files and documents
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB, Max. files: 20.
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Health Insurance Submission Form

Primary policy holder information

Patient information