INAYAH Claim

Provider- OP Direct Billing Claim Form

Details of the Third Party Administrator

Toll free/ Phone Number: 800-462924 / 04 3552354

Fax: 04 3512339

To be filled by the Insured / Patient

Patient

Gender

DOB

Inayah IDP

Corporate Name:

Inaya

Policy Ref

Name of Insurance Company:

Inayah TPA L.L.C

Contact Number:

Patient’s Declaration:
I declare that all the details given on this claim form are true and accurate and I hereby warrant the truth of the foregoing particulars in every respect and I agree that if have made or shall make any false or untrue statement, suppression or concealment my right to claim reimbursement of the said expenses shall be absolutely forfeited. In case INAYAH LLC is not liable to settle the hospital bill to discrepancy in documentation, I take complete responsibility to settle the bill. For this claim I authorise any medical practitioner, Specialist, Conultant who has attended me/the patient, in the past or present, to give any details that may be asked by INAYAH TPA LLC

Patient's/Member's Signature

Date

To be filled by the treating Doctor / Hospital

Nature of illness/Present complaints:

Duration of the Present ailment:

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Duration of the Present ailment:

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Past medical history if any:

Provisional Diagnosis:

Type of condition:

Acute

Chronic

Line of Treatment :

Medical Management

Investigation

Radiology

Pharmacy

Provider/Treating Physician Stamp:

Treating Physicians Name

Tel Number:

Fax Number:

Medical Plan ( Itemized Orginal Invoices and Applicable Prescriptions/ Reports/ Results must be enclosed to consider claim)

Pharmacy - Please attach a copy of prescription Dosage

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Laboratory/ Radiology Estimated Cost

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Hospital Declaration:
We have no objection to any authorized official documents pertaining to insured’s hospitalization. All valid original documents countersigned by the insured to be dispatched to INAYAH LLC, Dubai office within 7 days of the patients’ discharge. All non-medical expenses and expenses not relevant to the hospitalization or illness which is not payable by INAYAH LLC to be collected from the patient. INAYAH LLC will not be liable to make the payment in the event of any discrepancy between the facts presented at the time of submission of final documentation and pre-authorization request. The patient declaration has been signed by the patient or his representative in our presence

Provider’s Seal

Treating Doctor’s Signature

Patient/Insured Signature Parent signature in case of minor

Patient/ Insured Name