Claims Reimbursement

Reimbursement Reason*

Please state the reason for making out of Pocket payment at the hospital

Hospital Name*

What the name of the Hospital?

Visit Date*

What date did you visit the Hospital?

Reason for Visit*

Indicate reason for Hospital visitation

Reason for Visit

Other reasons for visit

Claim Amount*

What’s the Total Amount being claimed?

Authorization Code*

Approval Code given by Leadway.

Receipts Upload*

Please upload receipts showing breakdown of services with cost and evidence of payment

Medical Report (Required for secondary care only)

Please upload a medical report

Member Full Name*

Member Phone Number*

Member Enrollee Number*

Member Email Address*

Bank Name*

Account Number*

Account Name*

Comments

Any additional information

By proceeding, you agree to our data privacy policy and to collection and processing of your personal data

This field should be left blank

Company