Medical Claim Form
Claim reimbursement for medical and healthcare services online using our Medical Claim form. Whether you are a hospital or a private practice, modernize the process of requesting claims for services provided from insurance companies. Customize the form to match your company branding. Add fields and controls to extend the form, including collecting files and patient signatures. Embed the form into your website and use it on any mobile device.
Structure and logic of the form
-
The form content is organized using Tabs.
-
The Email field accepts only data matching a specified pattern to ensure valid email entries. Choose from predefined patterns or create custom ones to verify customer information.
-
The Phone field accepts only 11-digit numbers to prevent input errors. It's done with the Masked Text field type.
-
If the patient is not the policyholder, an additional section is displayed to collect information about the member. This is implemented using JavaScript code.
-
A claimant enters the list of services and treatments in a table, including the procedure and diagnosis codes, description, price, and amount. Totals are automatically calculated for each row and table.