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Form 2

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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330 views

Form 2

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.

Uploaded by

info.arnts
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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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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