7/26/2019 Agrahara Claim Form (Sinhala)

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7/26/2019 Agrahara Claim Form (Sinhala)

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Should be filled by the specialist / Surgeon of the Patient.

9.1 Name of the Patient:-

9.2 Diagnosis of Disease:-

9.3 Date of Admission:-

Date of Discharge:-

I hereby certify that I am specialist / Surgeon of the above named patient and approve submission with

regard to this claim.

.

Date:.. Signature of Specialist / Surgeon

7/26/2019 Agrahara Claim Form (Sinhala)

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