AXA Reimbursement Claim Form

Prior approval no:
When pre-authorisation required.
NB: In-patient treatment must be pre-authorised

Date received:

Dear Doctor, we thank you for filling in medical sections B, C and D of this claim form and for signing, dating and stamping it. Dear Member, we thank you for completing all other sections of this claim form and for signing and dating it. All fields on the front page are compulsory. We thank you in advance for your cooperation which will enable fast and accurate processing.

A. Administrative

Membership no:

Group/Company name:

Patient DoB:

Gender:

Patient name:

Policy/Group no:

Plan:

Patient phone:

Date of treatment:

Date of admission:

Date of Discharge:

B. Medical section

Symptoms presented:

Date the patient first became aware of any signs or symptoms for this condition:

Date on which the patient first presented to any doctor for this condition:

Medical condition/diagnosis:

Diagnosis :

ICD Code:

Investigation (Describe necessary investigations requested to define the diagnosis)

C. Treatment advised

Drugs:

D. Further treatment planned

Please give details of any further planned treatment:

E. Other insurer’s details

Is the treatment accident related? Yes No

Is it covered under another insurance policy? Yes No

If you have answered 'yes' to either of these questions, please give the name of the Insurance company involved.

Patient’s declaration

I confirm I am the patient, patient’s parent or guardian (if patient under 16 years of age) and wish to claim and declare that all the particulars given above are to the best 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 and to AXA Insurance. I agree that a copy of this consent shall have the validity of the original.
Signature:

Date :

I declare that I am the patient’s medical practitioner, and that the rticulars given are to the best of my knowledge true and correct.
Physician Name:
Stamp & Signature :

Date :

The member must complete the back of this form
You can download an Acrobat Reader writable version of this form from the www.axa-gulf.com website.

This part of the claim form aims at gathering additional information on the member in order to facilitate the processing of the claim. We thank you in advance for providing us the most complete information.

F. Administrative specific to reimbursement claims

Amount claimed:

Please ensure that the amount claimed here is supported by original invoices and prescription.

Cheque beneficiary name: (IN CAPITAL LETTERS)

Payment will be made in the currency defined in your plan unless we agreed otherwise in writing.

In which currency was the treatment originally billed?

Member’s and patient’s details
Patient’s name and address:

Telephone Number:

Fax Number:

Mobile Number:

Address to which payment should be sent if different from above:

G. Medical providers details:

Name of medical provider:

Telephone no:

Address of medical provider:

Fax no:

H. If you are claiming for treatment received outside your area of cover, please answer the following questions:

(a) Country where the treatment took place :

(b) The reason for the patient being abroad

Are you claiming cash benefit for in-patient treatment? Please tick Yes No

If Yes, please enclose a hospital certificate confirming the dates of stay: