Neuron Reimbursement Claim Form 2016

Dear Member,
Please make sure all sections of the form are filled. In case of any assistance please contact the Neuron toll-free helpline at the below numbers:
Within UAE: 800-4408

Outside UAE: +9714-3178500
The completed claim form should be returned back to Neuron along with all necessary documents applicable, as indicated below:
 Copy of radiology/imaging reports, blood test results, other reports for special/diagnostic procedures etc. (where you have paid and are claiming for
radiology/x-rays, imaging procedures e.g. Ultrasound, CT and/or MRI Scans, blood tests, etc.)
 Copy of the prescription/s (where you have paid and are claiming for medications)
 Discharge summary and medical report (in case you are claiming In-Hospital patient admissions).
 In case of surgical procedure, please attach operative notes, anesthesia sheets, and all histopathology reports.
 All invoices (with proper and detailed breakdown of amounts) and receipts (clearly showing that cash/credit card payment has been made by you).
 ANY MISSING INFORMATION MAY LEAD TO REJECTION.
Please fill the details below:
Details of member / patient:
Name of Patient: Contact Number:
Emirates I.D.: Email address:
Neuron ID: Date of Birth:
Name of Principal Member: Relationship to Principal member:
Payment Details:
Please choose payment type: Bank Transfer Cheque
1. Bank Transfer – (Please complete all details to enable bank transfer payments)
Account/Payer Name: Payment Amount/Currency:
Bank Name: Bank Address:
Swift Code: Account Number:
IBAN Number: | | | | | | | | | | | | | | | | | | |
Is this claim due to accident/injury? Yes No If yes, include medical information.

Date of accident/injury (dd/mm/yyyy) ______/______/____________
Have you obtained a prior approval for the requested services? Yes No
Details of Medical Condition: (To be filled in by the treating physician)
Date of Visit: ______/______/____________

Medical Condition requiring treatment:
Please provide the preliminary and final diagnosis with a brief summary of the case management:
Date of onset of symptoms: ______/______/____________

Date of first consultation related to the above case: ______/______/____________
I declare that I am the patient's treating Physician, and that the particulars given are to the best of my knowledge true and correct
Name of treating Doctor: Telephone:

Address of treating doctor / clinic: (please include city and country) Signature of Treating doctor with Stamp:
Date: ______/______/____________
Member’s declaration: (To be signed by the member or in case of minor by the principal member / guardian)
I confirm I am the patient (or the patient's parent or guardian if the patient is under 16 years of age) and wish to claim benefits
Name & Signature of the Member / Principal Member /
and declare that all the particulars given above are to the best of my knowledge true and correct. In respect of any medical
Guardian
claim. I hereby consent to and authorize the medical practitioner, health professional or other relevant medical establishment
to provide and discuss any health/treatment details, medical records or discharge arrangements (past and present) with and to
_______________________________________________
the Insurer and/or Third Party Administrator representative. I agree that a copy of this consent shall have the validity of the
original.
Date: ______/______/____________
The claim form should be submitted within 90 days of start date of the treatment along with all original receipts/invoices as per the policy membership agreement. Claims will
not be considered if not submitted within 90 days of treatment being received.
For Neuron Internal Use only:
Received Date: Claim I.D. No.:
________________________________________________________________________________________________________________________________________________
REIMBURSEMENT CLAIMS
REQUIREMENTS CHECK LIST
DESCRIPTION PROVIDED COMMENTS
Completed neuron claim form

YES NO
Patient's detail (name,

neuron id, signature)
YES NO
Diagnosis , treatment and history

YES NO
Doctor's signature & stamp/clinic stamp

YES NO
Original clinic invoices with proper breakdown of treatment

costs and or, medications given with corresponding costs.
YES NO
Pathology results/radiology results/laboratory results (if done)

YES NO
Medical report and, or discharge summary (incase patient was

admitted in the hospital)
YES NO
Original prescription for medicines and corresponding

receipts/invoice/proof of payment
YES NO
Original pharmacy invoices/receipts with paid stamp with

proper breakdown of costs
YES NO
ENGLISH/ARABIC TRANSLATION OF DOCUMENTS IF

WRITTEN IN FOREIGN LANGUAGE (If treatment done was
outside UAE) *This can YES NO
be requested from the hospital/clinic prior to issuance of the
documents
Annual leave details (from hr) once treatment done was on

annual leave
YES NO

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Dear Member,

Within UAE: 800-4408

Please fill the details below:

Details of member / patient:

Name of Patient: Contact Number:

Emirates I.D.: Email address:

Neuron ID: Date of Birth:

Name of Principal Member: Relationship to Principal member:

Please choose payment type: Bank Transfer Cheque

Account/Payer Name: Payment Amount/Currency:

Bank Name: Bank Address:

Swift Code: Account Number:

Is this claim due to accident/injury? Yes No If yes, include medical information.

Details of Medical Condition: (To be filled in by the treating physician)

Date of Visit: ______/______/____________

Date of onset of symptoms: ______/______/____________

Name of treating Doctor: Telephone:

Received Date: Claim I.D. No.:

DESCRIPTION PROVIDED COMMENTS

Completed neuron claim form

Patient's detail (name,

Diagnosis , treatment and history

Doctor's signature & stamp/clinic stamp

Original clinic invoices with proper breakdown of treatment

Pathology results/radiology results/laboratory results (if done)

Medical report and, or discharge summary (incase patient was

Original prescription for medicines and corresponding

Original pharmacy invoices/receipts with paid stamp with

ENGLISH/ARABIC TRANSLATION OF DOCUMENTS IF

Annual leave details (from hr) once treatment done was on

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Date of Visit: //________

Date of onset of symptoms: //________