Claim Form

No. PCF/19/20230102/3





   Date:         [DateOfVisit]

   Provider:        [ProviderName]

   PATIENT INFORMATION
   Patient's Name(as on card):             [PatientName]
Mr Ms Mrs
   Card #    [CardNumber]    Policy No.       BirthDate:    [DOP]

    Sex:

   INFORMATION                                                                                                                                                                        To be completed by Physician
   Service Date     [DateOfVisit]    Symptom(s) as described by
   patient    

Pre-existing Condition(s) being treated
Chronic Medications
Family History of any illness
   If Yes
   Specify:   
   OBJECTIVE/ASSESSMENT                                                                                                                                                        To be completed by Physician
   Clinical    
   Findings    [ClinicalFindings]

   Cause Accident Dental Maternity Physical
Illness		 Preventive Psychiatry Work
Related

   Other(s),Explain

   Assessment/Diagnosis Acute Chronic Confirmed Suspected

   Comments       [Diagnosis]

   MEDICAL PLAN
Itemized orginal Invoices & Applicable Prescriprions/Reports/Results Must be enclosed to consider the claim
Consultation Physiotherapy Laboratory Radiology Pharmacy Other
   Pre Authorization
   Required for:

   Full details of proposed treatment/ Surgery/ Medicine:

   EstimatedCost

   For Almadallah's Use Only

   As per agreed tariff

   ApprovalCode



   IN-PATIENT
   Discharge summary, Itemized Invoices, Report, and 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     [PatientTel]



   Signature and stamp    


   Date   [Date]

   Date