Voucher Number:
1. Patient’s Name:
2. Patient Health Card no./ Emirates ID No.:
3. Group Member Name:
4. Reason for not using listed Healthcare facilities:(Kindly indicate)
Emergency Elective Service not Available On vacation/ buisiness trip outside the UAE
Emergency Elective Service not Available On vacation/ buisiness trip outside the UAE
Other's Please specify
5. Medical information:(To be filled by treating doctor for all outpatient treatment. For cases like hospitaliztion procedures and surgeries, a detailed medical report is required)
Condition requiring treatment:
Date :
Onset Duration Illness:
Treatment Details:
I declare that I have attended to this patient and that the particulars given are to the best of my knowledge true and correct.
Name & signature of the doctor::
Date :
7. Other Information
Is the above case work related ?
No
Yes(full details)
Is the claim covered by another insurance ?
No
Yes(Pls specify the amount reimbursed and by which insurance company)
8. Declaration:
I, the undersigned, hereby declare that the information above is true and complete and that reimbursemnt requested is for expenses paid by me for the treatment of my medical condition.
I agree to submit to ADNIC any mandatory/deemed necessary requested document to process my above claim. I here by authorize ADNIC to approach any doctor/medical facilty/any institution or any person who has any record/medical information about me or my family member, to provide ADNIC with complete information inclding copies of the records when requested.
PREFERENCE - MODE OF SETTLEMENT
1.
Cheque
2.
Bank/ Wire transfer
If Bank/Wire Transfer, please fill in the below authorization form.
AUTHORIZATION FORM FOR BANK/WIRE TRANSFER
Authorization
I, the undersigned , hereby authorize Abu Dhabi National Insurance Company(ADNIC) to wire transfer the amount of my claim under this form to the following bank account:
BANK NAME:
IBAN NUMBER:
EMAIL ID:
MOBILE NUMBER:
Member Name & Medical Insurance card number :
/
Contact No.:
Date :