Refund Request Form

Apex Membership Number

Facility Visited

Date of visitation

Name of Company

Telephone Number

Refund Amount (GHC)

Diagnosis

Prescription

Referral Note

Receipt

Lab Request

Select Payment Option

Name on cheque

Name on Account

Bank name and branch

Account

Mobile Money Account Name

Mobile Money Number(MTN)

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