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    Reimbursement Form (Medical Part) : Section 1 - Member Information

    Uploaded by

    Mathews Jose
    This reimbursement form requests medical and financial information to process a medical claim. Section 1 requests patient and principal information. Section 2 is to be completed by a medical practitioner, providing country and date of treatment, diagnosis, and prescribed treatment. Section 3 lists claimed invoices. Section 4 requests bank details for settlement, noting that transfers outside the UAE may incur additional charges. The form notes that original documents and prior approval may be required to finalize claims.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Reimbursement Form (Medical Part) : Section 1 - Member Information

    Uploaded by

    Mathews Jose
    51 views2 pages
    This reimbursement form requests medical and financial information to process a medical claim. Section 1 requests patient and principal information. Section 2 is to be completed by a medical practitioner, providing country and date of treatment, diagnosis, and prescribed treatment. Section 3 lists claimed invoices. Section 4 requests bank details for settlement, noting that transfers outside the UAE may incur additional charges. The form notes that original documents and prior approval may be required to finalize claims.

    Original Title

    myNASReimbursementClaimForm-1

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    This reimbursement form requests medical and financial information to process a medical claim. Section 1 requests patient and principal information. Section 2 is to be completed by a medical practitioner, providing country and date of treatment, diagnosis, and prescribed treatment. Section 3 lists claimed invoices. Section 4 requests bank details for settlement, noting that transfers outside the UAE may incur additional charges. The form notes that original documents and prior approval may be required to finalize claims.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    51 views2 pages

    Reimbursement Form (Medical Part) : Section 1 - Member Information

    Uploaded by

    Mathews Jose
    This reimbursement form requests medical and financial information to process a medical claim. Section 1 requests patient and principal information. Section 2 is to be completed by a medical practitioner, providing country and date of treatment, diagnosis, and prescribed treatment. Section 3 lists claimed invoices. Section 4 requests bank details for settlement, noting that transfers outside the UAE may incur additional charges. The form notes that original documents and prior approval may be required to finalize claims.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Reimbursement Form (Medical part)

    Please Use BLOCK letters to fill this form, and ensure that all sections are completed.

    Section 1 - Member Information

    Patient name (as printed on card)

    Patient card number DOB

    Principal name (as printed on

    Principal contact information E-mail: Mob:

    Section 2 - Medical Information


    (To be fully completed by patient’s medical practitioner - all boxes must be completed in BLOCK letters.)

    Country of treatment Provider name and contact information

    Date when first symptoms were noticed Physician name and contact information

    I declare that I am the patient’s medical Physician signature and official stamp
    practitioner, and that the particulars given are to
    the best of my knowledge true and correct.

    Date / /

    Please provide details of diagnosis (primary and secondary) or symptom(s) and prescribed treatment(s) or investigation(s).

    Symptoms:

    Diagnosis:

    Treatment / investigation:

    Patient name Card number


    Reimbursement Form (Financial Part)

    Section 3 - Claimed Invoices


    No. Invoice number Claimed amount Currency No. Invoice number Claimed amount Currency

    Total claimed amount per currency:

    Section 4 - Settlement (Kindly ensure bank details are in print form)

    Settlement currency: Settlement by: Cheque Wire Transfer

    (A) Bank name (B) Account holder name

    (C) IBAN number / Account number (D) SWIFT code

    (E) Bank address (F) Beneficiary address

    Important Notes:
    Please submit the medical reports from your treating physician, pharmacy prescriptions, investigations requests and their results, invoices with itemized breakdown
    and original receipts. In case of online submission, please retain the original documents as they may be required to finalize your claim.
    NAS prior approval is required for all non-emergency hospitalizations. Before admission, you are kindly required to e-mail a detailed medical report and cost
    estimate of the proposed treatment on official letterhead duly signed and stamped by the treating physician to [email protected].
    Cheques are issued in the name of the principal and are valid for 6 months from the date of issue.
    For your convenience, bank account details can be saved and available for editing on your profile page on myNAS portal https://mynas.ntouch.cloud
    For transfers within the U.A.E., fields (A), (B) and (C) are mandatory. For transfers outside the U.A.E., please complete all fields in the settlement section above. In case
    IBAN is not available in the destination country please enter bank account number in lieu of IBAN number. Please note that transfers outside the U.A.E. are subject to
    charges that may be applied by your bank.
    NAS bears no liability for any incorrect bank account details provided above. Furthermore, any charges related to corrective action shall be deducted from the final
    settlement.
    All Documents must be submitted in English or Arabic, documents in other languages must be translated prior to submission.

    Signature of the principal and or spouse

    Date / / 20

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