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    Nas Claim Form

    Uploaded by

    ehtsham007
    This reimbursement claim form contains sections for the member/patient details, medical information filled out by the treating physician, other insurance details if the treatment was due to an accident or covered by another policy, patient treatment and cost details, and a signed patient declaration authorizing the release of medical information and consenting to the claim. The form is used by NAS or their toll free number when patients are seeking reimbursement for medical costs covered by their insurance plan.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nas Claim Form

    Uploaded by

    ehtsham007
    3K views1 page
    This reimbursement claim form contains sections for the member/patient details, medical information filled out by the treating physician, other insurance details if the treatment was due to an accident or covered by another policy, patient treatment and cost details, and a signed patient declaration authorizing the release of medical information and consenting to the claim. The form is used by NAS or their toll free number when patients are seeking reimbursement for medical costs covered by their insurance plan.

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    This reimbursement claim form contains sections for the member/patient details, medical information filled out by the treating physician, other insurance details if the treatment was due to an accident or covered by another policy, patient treatment and cost details, and a signed patient declaration authorizing the release of medical information and consenting to the claim. The form is used by NAS or their toll free number when patients are seeking reimbursement for medical costs covered by their insurance plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3K views1 page

    Nas Claim Form

    Uploaded by

    ehtsham007
    This reimbursement claim form contains sections for the member/patient details, medical information filled out by the treating physician, other insurance details if the treatment was due to an accident or covered by another policy, patient treatment and cost details, and a signed patient declaration authorizing the release of medical information and consenting to the claim. The form is used by NAS or their toll free number when patients are seeking reimbursement for medical costs covered by their insurance plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Reimbursement Claim Form

    If you have any questions regarding this form or any other aspects of your cover, Please telephone
    NAS (+9712 6940800) or Toll Free 800 2311

    Details of member/patient
    Employee Name Your Insurance Card No

    Patients name and address

    Employee No/ Staff ID No:

    Company Name Date of birth / /

    Employees Email address Employees Tel number

    Nationality

    Medical section (To be fully completed by patients medical practitioner all boxes must be completed in block capitals.)

    Physicians name and address Date symptoms first noticed

    I declare that I am the patients medical practitioner, Physicians Signature and stamp
    and that the particulars given are to the best of my
    knowledge true and correct.

    Date / /
    Diagnosis

    Other insurers details (If the treatment is accident-related or covered under another insurance policy please provide name of insurance company.)

    Patient Section
    Out Patient Treatment Claimed Amount In Patient Treatment Claimed Amount
    Consultation Hospital charges/
    Room
    Pharmacy Surgery/Anesthesia/OT

    Diagnostic/Lab/Others Drugs/Labs/Others

    Country of Treatment

    Total Claimed Amount and Claimed Currency

    Patients declaration and consent


    I confirm I am the patient/patients spouse or guardian (if patient under 16 years of age)
    and wish to claim benefits and declare that all the particulars given above are to the best Signature
    of my knowledge true and correct. I hereby consent to and authorise the medical practitioner
    involved in the patients care to discuss treatment details and discharge arrangements with Date / /
    and to NAS. I agree that a copy of this consent shall have the validity of the original.

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