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Gulfcare Insurancec Claim Form

This reimbursement claim form collects information about the patient, their medical condition and treatment, and any costs incurred. The form requires details about the member and patient, information from the treating medical practitioner about the condition and treatment, and a breakdown of any outpatient or inpatient costs being claimed. The patient must sign to consent to the claim and authorize the insurer to discuss treatment details with the medical provider. The completed form along with original receipts must be submitted within 90 days of starting treatment.

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rishijaveri
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1K views1 page

Gulfcare Insurancec Claim Form

This reimbursement claim form collects information about the patient, their medical condition and treatment, and any costs incurred. The form requires details about the member and patient, information from the treating medical practitioner about the condition and treatment, and a breakdown of any outpatient or inpatient costs being claimed. The patient must sign to consent to the claim and authorize the insurer to discuss treatment details with the medical provider. The completed form along with original receipts must be submitted within 90 days of starting treatment.

Uploaded by

rishijaveri
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Reimbursement Claim Form

If you have any queries about this form or your scope of cover, please telephone NAS (+9712 6940700) or Toll Free 800 2311.

Details of Member/Patient
Members name

Membership number from your card

Patients name and address


Staff ID No.
Date of Birth

Email address

Tel number

Patients relationship to member

Fax number

Medical Section (To be fully completed by patients medical practitioner all boxes must be completed in block capitals.)
Medical practitioners name and address

Date symptoms first noticed


Tel number
Fax number

I declare that I am the patients medical practitioner, and that the


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

Signature

Date

Medical practitioners stamp

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 insurers 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

Amount

In Patient Treatment

Consultation

Hospital charges/ Room

Pharmacy

Surgery/Anesthesia/OT

Diagnostic/Lab/ Others

Drugs/Lab/Others

Total Amount in AED

Total Amount in AED

(Please specify if other 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 particulars given above to the best 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 and to NAS. I agree that a copy of this consent shall have the validity of the original.

Signature
Date

The claim form must be submitted within 90 days of start of the treatment along with all original receipts/invoices. Send this claim form
together with supporting material to: GulfCare, C/O Marsh Insco LLC, 9th Floor, Abdulla Bin Darwish Bldg /RBS Bldg.

P.O. Box 54733, Abu Dhabi, United Arab Emirates.

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