NGI Reimbursement Claim Form

REIMBURSEMENT FORM FOR OUT OF NETWORK TREATMENT

INSTRUCTIONS: Please read the following information carefully before filling this form

Please fill Section A of this form and request your doctor to fill up Section B.
Please attach the following supporting documents to your claim form.

a. Original Itemized Bills/ Invoices
b. Original Payment Receipts / Credit Card Slips
c. Original Prescriptions
d. Original Discharge Summary
e. Copies of Laboratory and Radiology Reports
f. Copies of Operative Notes and Histopathology Report in case of surgery
g. Copy of Birth Certificate in case of Child Birth
h. Copy of Pre-authorization Letter from HealthNet
i. Legal translation of all documents in case are in any language other than Arabic or English.

Please Send your claim within 90 days of your treatment date to Medical Claims Department at the following address:.
National General Insurance Co,. 5th Floor, NGI House, Port Saeed, Deira, P.O. Box 154, Dubai.

If you have any difficulty filling this form, please contact our Customer Service Desk during office hours (08.00 am to 05.00 p.m. except Friday 7 Saturday) Telephone: +971 42115 800 or E-mail: customerservice@ngiuae.com

Section - A: Policyholder's Details(to be completed by the insured)

1. HealthNet Policy Card No.:

2. Name of Policy Holder

Date of birth*:

Sex:

3. Name of Employee (if different from policyholder):

4. Patient's relationship to insured:

Self Spouse Dependent Child

5. Contact Numbers:(Mobile)

(Others):

6. Email Address:

7. Total Claimed Amount (in original currency):

Declaration/ Authorization:
I certify that all information contained in / Provided with the claim is complete and correct. I hereby authorize any doctor, hospital, clinic or medical provider, any insurance company or any other organization or person who has medical record or information about me and / or of my family members (if covered under HealthNet Insurance Policy) to furnish it to National General Insurance Co. (PSC). Any photocopy of this declaration / authorization shall be deemed as effective as the original.

Signature of Policyholder
(Self & on behalf of Family Member)
Date :

Signature & Seal of the Employer / Sponsor
( Optional For Group Scheme Only)
Date :

Section - B: Patient's Details (to be completed by Treating Doctor)

1. Name of the Patient:

Date of birth*:

Sex:

2. Name of Treating Physician / Surgeon:

Speciality:

License/ Registration No.:

3.Name & Address of Hospital / Clinic:

Telephone No.:

Email Address:

4. Are you the Patient's primary physician ?

Yes No

5.Presenting Complains:

6.Duration of Symptoms:

7. Onset of Conditions:

8. Relevent Past Medical/ Surgical History:

9.Diagnosis :

ICD Code:

10. Etilogy:

11. Plan/ Details of Management:

12. In case of Hospitalization:

Date of Admission:

Date of Discharge:

Signature & Seal if Treating Physician/ Surgeon:

Date:

Section- C: For Office Use Only(to be completed by Claims Manager)

Remarks: