Banking Details Verification Form

Bank Details Verification Form

IMPORTANT NOTE: I/We declare that the details on this Banking Verification form are correct and may be used by Prime Cure Health for reimbursement of valid claims. I/We authorise Kaelo Prime Cure to pay any amounts due to the stated provider’s account into the mentioned bank account. Service providers are requested to complete this form online, kindly accompany the form with a certified ID copy of the bank account holder and bank stamped confirmation letter (both not older than three (3) months).

Provider Details:

Practice Name

Practice Registration Number

Postal Address

City

State/Province

Zip/Postal

Country

Postal Address

Telephone Number

Fax Number

Email Address

Name of Contact Person in Practice

Banking Details:

Account Holder

Bank Name

Account Number

Branch Name

Branch Code

Account Type

Transmission

Cheque

Savings

Initials and Surname

Signature

Clear

Certified ID of Account Holder

Maximum file size: 2.1MB

Stamped bank confirmation letter not older than three (3) months

Maximum file size: 2.1MB

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