Self Assessment
SAICO Reimbursement Claim Form
SectionA :To be completed by the insured member .القسم أ: يم العضو المؤمن البيانات في ھذا القسم
Patient detail
.القسم أ: يم العضو المؤمن البيانات في ھذا القسم
.
Member No :
رقم الع ضو
.
Employee No :
رقم الموظف
.
Birth Date :
تاريخ المي د:
.
Patient Name :
: اسم المريض
.
Email Address :
عنوان البريد ا"لكتروني
.
Mobile No :
: رقم الھاتف الجوال
.
Treatment detail
.القسم أ: يم العضو المؤمن البيانات في ھذا القسم
.
Country of Treatment :
UAE
لد الع ج
Date of Treatment :
تاريخ العلاج
.
Date of first seen :
تاريخ أول زيارة
.
Break DOwn of expence required
(إلزامي (المصروفات تفصيل
.
Currency of Expenses:
عملة دفع المصروفات
Dirham
Doctor's Fees (Consultation):
رسوم الطبيب (ا2ستشارة)
Medicines:
ا6دوية
Others (lab, x-rays, dental, vision, etc.):
أخرى (المعمل، أشعة إكس، ا6سنان، الرؤية، أخرى)
Total Amount Claimed:
لمبلغ ا"جمالي المطلوب
Reimbursement Details
تفاصيل السداد
.
Pay to (Benficiary name)
( يُدفع إلى (اسم المستفيد
.
Healthcare Provider:
PATIENT INFORMATION
Patient’s Name (as on card):
Card #
Policy No.
Birth date
Sex
Reason for Not using Almadallah Healthcare Facilities:
Emergency
Family Doctor
Preferred Personal Choice
Service not available
on vacation/business trip outside UAE
Other(s) please specify
INFORMATION
To be completed by Physician
Date of present symptoms:
Symptom(s) as described by Patient:
Pre-existing Condition(s) being treated for:
NO
Yes
If Yes Specify:
Chronic Medications:
NO
Yes
If Yes Specify:
Family History of any Illness:
NO
Yes
If Yes Specify:
OBJECTIVE/ASSESSMENT
To be completed by Physician
Clinical Findings :
Cause
Physical Illness
Accident
Maternity
Preventive
Psychiatric
Dental
Work Related
Other(s), Explain:
Assessment/Diagnosis
Acute
Chronic
Confirmed
Suspected
MEDICAL PLAN
(itemized original invoices & applicable prescriptions/ reports/ results must be enclosed to consider the claim)
Currency (if treatment availed outside UAE)
IN-PATIENT
T (discharge summary, itemized invoices, report, results should be attached)
Length of stay:
Provider:
Cost:
The above information is true to the best of my knowledge. I hereby authorize any Healthcare Provider, Insurer, Employer or other Organization to release any information regarding my medical conditions & history to ALMADALLAH for the purpose of determining insurance benefits
Treating Physician Name:
Patient/Guardian signature
Tel./Fax:
Signature & Stamp
Patient Signature
Print
