QLM Life & Medical Insurance Company Q.P.S.C.

Licensed and Regulated by the Qatar Central Bank vide Commercial Registration No. 116849

e-Reference No.
Reimbursement Claim Form
Provider: Medical Record No.: Date:
dd / mm / yyyy
Patient Name: E-mail: Age/DOB:

MEM: Mandatory Qatari/Civil ID: Gender: F M

Marital Status: Policy Holder: Policy No.:

Payment to: Member Employer Payment Method: Cheque Bank Transfer

In case bank transfer is selected, Bank Name: Account No.:

Swift Code/IBAN: Bank Address:

New Visit Follow-up OP ER Day care IP

In case of in-patient admission, Admission Date: dd / mm / yyyy Discharge Date: dd / mm / yyyy

To be filled by Medical Practitioner

Present Illness Details: Past Medical History:
……………………………………………………………………………. …………………………………………………………………………….

…………………………………………………………………………….. ……………………………………………………………………………..

…………………………………………………………………………….. ……………………………………………………………………………..

Acute Chronic Accident Hereditary/Congenital Work Related Pregnancy LMP: dd / mm / yyyy

Diagnosis: Mandatory Duration of Illness: Mandatory

Lab / Radiology:

Code Procedure Cost (Currency)

.............................. …………………………………………………………………………………………… ………………………….

……………………….... …………………………………………………………………………………………… …………………….…..

…………………………. …………………………………………………………………………………………… …………………………

Medical Practitioner Declaration Patient Declaration

I hereby certify that all medical information mentioned is to I hereby certify that the entire particulars given above are
the best of my knowledge true and the medical services true. I hereby authorize QLM Life & Medical Insurance
shown on this form are medically indicated & necessary for Company to discuss, access and obtain a copy of my health
the management of the patient medical condition. records (or any of my dependents’ records) that may be
requested by them or their appointed representative. I also
Treating Physician:
agree that acopy of this declaration stands valid as original.
Specialty: Patient Signature (above 18 years):
Contact No.:
Parent / Guardian Signature (below 18 years):
Signature or Stamp:
Date:
Mobile No.:

Tamin St., West Bay, P.O. Box 201233, Doha, Qatar Toll Free: 8000 880 Outside Qatar: +974 44533666 Fax: +974 44839188
www.qlm.com.qa
 QLM Life & Medical Insurance Company QPSC
(Regulated by the Qatar Central Bank vide Commercial Registration No. 116849)

(Privacy notice) for medical claims data collection forms: This privacy details about our retention periods. We will not hold or process
notice explains what type of personal data will be collected, how and excessive personal data.
why it is collected and to whom it is shared or disclosed. (Children): Depending on age requirements or the nature of service
(Controller) who we are: QLM Life & Medical Insurance Company requested, where it is necessary to process a child’s personal
QPSC. (“we”, “us” “our”), is a leading life and health insurance information on the basis of consent, we may need the consent of the
company that brings innovative and tailor-made insurance solutions person with parental responsibility for the child. This will be specified
coupled with world class level of service. Protecting your privacy is a on the form if applicable.
top priority for us. (Your rights) under data protection law:
(Purposes) why do we need your personal information and what do • Access to your information – you have the right to request a copy
we do with it? The purpose of collecting the information in this form of the personal information that we hold about you.
is for medical claims processing and settlement.
• Correcting your information – we want to make sure that your
(Lawful basis) for using your information: The processing ground of personal information is accurate, complete, and up to date. You may
the information provided in this form is through explicit consent to ask us to correct any personal information.
process medical information
• Deletion of your information – you have the right to ask us to delete
(Sharing) who do we share your information with? We may share personal information.
your health and other data with the institutions set out below for
• Objecting to how we may use your information – you have the right
them to use to the same extent, and for the same purposes as us. We
to tell us to stop using your personal information.
may share necessary information to co-insurers to distribute the
coverage of the insurance risk jointly with other companies to which • Restricting how we may use your information – in some cases, you
QLM issue the policy, and to handle claims jointly. We may share may ask us to restrict how we use your personal information.
necessary information to other co-insurers/re-insurers that may be • Withdrawing consent to use your information – where we use your
covering the same insurance risk at the same time through multiple personal information with your consent you may withdraw that
insurance to distribute the payment of any compensation that may consent and we will stop using your personal information for the
be owed to you, or to collaborate in the detection or prevention of purpose(s) it was given.
fraud and financial crime.
Please see contact us if you wish to exercise any of these rights.
(international transfers) if any apply: Your personal data may be
(Contact us):You can contact our data protection officer about any
processed both inside and outside of the European Economic Area
data protection matter by post at this address: c/o Data Protection
(EEA) by the parties specified above, subject always to contractual Officer, QLM Life & Medical Insurance Company QPSC, P.O Box:
restrictions regarding confidentiality and security in line with 12713, QLM Building, Tamin Street, West Bay, Doha, Qatar; by email
applicable data protection laws and regulations. We will not disclose at: [email protected] and by telephone on: T: +974 4404 0600,
your personal data to parties who are not authorized to process them.
F: +974 4404 0666
Whenever we transfer your personal data for processing outside of
(Complaints): Our data protection officer aims to directly resolve all
the EEA, we will do so on the basis of the data processing agreement
complaints about how we handle personal information. See contact
which establishes adequate protection for personal data and are
us above. However, you also have the right to lodge a complaint
legally binding. We will take steps to ensure that the transfer of your
about a data protection matter with the supervisory authority of
personal data outside of the EEA receives an adequate level of Qatar.
protection as it does in the EEA. You can find out what safeguards we
rely upon for such transfers by contacting us as detailed below.
(Storage) how long do we keep your information for? The personal
data and health data collected will be retained for a period of time
which is equal to the duration of your policy with us (including any
renewals thereof) and for the period defined as per legal and
regulatory requirements from the date the policy expires, save for
cases where a longer retention period is required for possible
disputes, requests of the competent authorities or pursuant to the
applicable laws. Once the retention period is over the data will be
deleted or anonymized. You can contact us if you require further