BEEASSIST HEALTH INSURANCE
REIMBURSEMENT CLAIM FORM

Policy Number: POL-1001
Member ID: M-1001-01
Patient Name: Priya Nair
Date of Birth: 12/03/1984
Claim Type: Pharmacy
Pharmacy Name: MedPlus Pharmacy
Provider ID: PRV-204
Date of Purchase: 20/08/2026
Diagnosis: Asthma
ICD-10 Code: J45.909
Total Amount Claimed: Rs. 3,240.00
Date of Submission: 05/09/2026
