MEMBER REFUNDS

APEX MEMBERSHIP NUMBER

NAME OF COMPANY

TELEPHONE

NAME OF HEALTH FACILITY VISITED

REASON FOR REFUND

RELEVANT DOCUMENT BEING ATTACHED

PRESCRIPTION

REFERRAL NOTE

RECEIPT

LAB. REQUEST

SIGNATURE UPLOAD

TOTAL REFUND AMOUNT (GHC)

DOCUMENT UPLOAD

DIAGNOSIS

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BANK TRANSFER DETAILS

CHEQUE DETAILS

MOBILE MONEY DETails

NAME ON ACCONT

BANK NAME AND BRANCH

ACCOUNT NAME

MTN MOBILE MONEY NUMBER

NAME ON CHEQUE

ACCOUNT NUMBER

I CONSENT TO APEX HEALTH INSURANCE COLLECTING MY PERSONAL INFORMATION TO PROCESS REFUNDS THROUGH THIS PORTAL. BY SUBMITTING THIS FORM, YOU AGREE THAT WE MAY PROCESS YOUR INFORMATION IN ACCORDANCE WITH THE DATA PROTECTION ACT, 2012 (ACT 843) TO PROTECT THE PRIVACY OF THE INDIVIDUAL.

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