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  • Claim Form 1

    Загружено:

    raveemeduri
    25 просмотров1 страница
    This document appears to be a medical claim form for an employee health insurance scheme. It requests information such as the patient's name, sex, employee ID number, date of injury or illness, diagnosis, treatment details including services provided, drugs prescribed, treating physician and hospital. It also has sections for accounting information such as doctor's fees, drugs, tests and total amount. It requires the form to be submitted to the employer along with payment confirmation for reimbursement under the scheme.

    Исходное описание:

    ME G U F L

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    © © All Rights Reserved

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    This document appears to be a medical claim form for an employee health insurance scheme. It requests information such as the patient's name, sex, employee ID number, date of injury or illness, diagnosis, treatment details including services provided, drugs prescribed, treating physician and hospital. It also has sections for accounting information such as doctor's fees, drugs, tests and total amount. It requires the form to be submitted to the employer along with payment confirmation for reimbursement under the scheme.

    Авторское право:

    © All Rights Reserved
    Скачайте в формате PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    25 просмотров1 страница

    Claim Form 1

    Загружено:

    raveemeduri
    This document appears to be a medical claim form for an employee health insurance scheme. It requests information such as the patient's name, sex, employee ID number, date of injury or illness, diagnosis, treatment details including services provided, drugs prescribed, treating physician and hospital. It also has sections for accounting information such as doctor's fees, drugs, tests and total amount. It requires the form to be submitted to the employer along with payment confirmation for reimbursement under the scheme.

    Авторское право:

    © All Rights Reserved
    Скачайте в формате PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 1

    Capital SR 125,000,000 Fully Paid-up 125,000,000

    Scheme:
    THE EMPLOYEE / DEPENDENT
    (If employee membership card available show impression
    in box and leave following items blank)

    Name: Sex: Male / Female


    ...
    (Delete as applicable)
    Badge or Employee Number: ..

    Date: / /
    Signature of Claimant ..

    ACCOUNTING INFORMATION
    TREATMENT INFORMATION
    Doctors fee
    Date of Injury or
    Commencement of Illness: Drugs
    Date of consultation: X - Rays
    Date first seen (if ongoing treatment): Laboratory
    Diagnosis:
    Other (Please give details)



    Services Rendered:
    (e.g. Consultation, tests or investigations etc.)
    Total

    NOTE TO THE SCHEME MEMBER
    Drugs Prescribed: To obtain reimbursement this form must be given to your
    employer together with confirmation of payment

    Is ongoing treatment required in respect of this condition?


    YES / NO
    delete as applicable

    If yes, what additional treatment, tests or other


    investigations do you anticipate being necessary?
    Name of Hospital

    .
    Name of treating Doctor

    Signed Date

    Third Party Administrator: Medi Visa

    General Agents: Al Samiya Corporation - Head Office: P.O. Box: 2302 - Riyadh 11451 - Kingdom of Saudi Arabia - Telephone: (01) 477 9229 - Fax: (01) 478 9219 - e-mail: riyadh@medgulf.com

    e-mail: riyadh@medgulf.com - )01( 478 9219 : - )01( 477 9229 : - - 11451 - 2302 :. : - :

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