Guideline 09-02

ATENDIMENTO ACIONAMENTO ACOMPANHAMENTO RETENÇÃO GLOSSÁRIO
Solicitação do
atendimento:
Voltar para:
ACIONAMENTO
ASSISTÊNCIA VIAGEM
Greetings,
See below the request for a new medical case. Please, provide directions for the nearest hospital along with a GOP in our
behalf.
Policyholders (PH) full name:
Date of birth (Month/day/year):
Language(s) spoken by PH:
Travelling companion(s) (number + names):
Location and contact details of PH (All phone numbers must include country and area code):
Location and contact details of travelling companion(s) (All phone numbers must include country and area code):
Hospital/Clinic/Doctor contact details (if alpplies):
Nature of problem:
Limits in coverage:
Assistance requested:
Medical report requested: Yes
Cost guarantee requested: Yes
We kindly ask you to advise if a medical release form will be necessary, as we are going to need to obtain the medical report,
itemized hospital charges and invoice.
Thank you for your help. We’ll be expecting an answer shortly.
Best regards,