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    Form 2

    Uploaded by

    info.arnts
    This reimbursement claim form is for members to claim reimbursement for medical expenses covered by their insurance plan. It requests information such as the member and patient's name and contact details, the medical practitioner's details, dates of treatment, a description of the condition, and amounts being claimed. The patient declares that the information provided is accurate and consents to their medical practitioner discussing treatment details with the insurance provider. The form notes it must be submitted within 90 days of treatment with original receipts for the claim to be considered.

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    Download as PDF, TXT or read online from Scribd

    Form 2

    Uploaded by

    info.arnts
    172 views1 page
    This reimbursement claim form is for members to claim reimbursement for medical expenses covered by their insurance plan. It requests information such as the member and patient's name and contact details, the medical practitioner's details, dates of treatment, a description of the condition, and amounts being claimed. The patient declares that the information provided is accurate and consents to their medical practitioner discussing treatment details with the insurance provider. The form notes it must be submitted within 90 days of treatment with original receipts for the claim to be considered.

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    This reimbursement claim form is for members to claim reimbursement for medical expenses covered by their insurance plan. It requests information such as the member and patient's name and contact details, the medical practitioner's details, dates of treatment, a description of the condition, and amounts being claimed. The patient declares that the information provided is accurate and consents to their medical practitioner discussing treatment details with the insurance provider. The form notes it must be submitted within 90 days of treatment with original receipts for the claim to be considered.

    Copyright:

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

    Form 2

    Uploaded by

    info.arnts
    This reimbursement claim form is for members to claim reimbursement for medical expenses covered by their insurance plan. It requests information such as the member and patient's name and contact details, the medical practitioner's details, dates of treatment, a description of the condition, and amounts being claimed. The patient declares that the information provided is accurate and consents to their medical practitioner discussing treatment details with the insurance provider. The form notes it must be submitted within 90 days of treatment with original receipts for the claim to be considered.

    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 6940700) or Toll Free 800 2311

    Details of member/patient
    Member’s name Membership number from your card

    Patient’s name and address

    Staff ID No:

    Date of birth / /

    Email address Tel number

    Patient’s relationship to member Fax number

    Medical section (To be fully completed by patient’s medical practitioner – all boxes must be completed in block capitals.)

    Medical practitioner’s name and address Date symptoms first noticed

    Tel number

    Fax number

    I declare that I am the patient’s medical practitioner, Medical practitioner’s stamp


    and that the particulars given are to the best of my
    knowledge true and correct.

    Signature Date / /

    Medical condition requiring treatment

    Please give the date on which the patient first presented to any doctor for this condition

    Please give the full history of the medical condition requiring treatment including full details of any previous
    investigation/treatment together with relevant dates. Please also advise any further treatment planned.

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

    Details of Claimed Amount


    Out Patient Treatment Amount In Patient Treatment Amount
    Consultation Hospital charges/ Room
    Pharmacy Surgery/Anesthesia/OT
    Diagnostic/Lab/Others Drugs/Labs/Others
    Total Amount in AED Total Amount in AED
    (Please specify if other Currency)

    Patient’s declaration and consent


    I confirm I am the patient/patient’s 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 patient’s 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.

    The claim form should be submitted within 90 days of start of the treatment along with all original receipts/invoices – as per
    the policy membership agreement. Claims will not be considered if not submitted within 90 days of treatment being received.

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