Self Assessment
Almadallah Claim
Claim Form
استمـارة المطالبت
No:
Please complete all the fields
For Pre Approval kindly call our help Line for 24 Hours: 04 434 2322 Fax: +9714 434 2310
Date:
Healthcare Provider:
PATIENT INFORMATION
Patient’s Name (as on card):
Mr.
Mrs.
Ms.
Card #
Policy No.
Birth date:
Sex:
INFORMATION
To be completed by Physician
Date of present symptoms:
Symptom(s) as described by Patient:
Pre-existing Condition(s) being treated for:
NO
Yes
Chronic Medications:
NO
Yes
Family History of any Illness:
NO
Yes
OBJECTIVE/ASSESSMENT
To be completed by Physician
Clinical Findings
Cause
Physical Illness
Accident
Maternity
Preventive
Psychiatric
Dental
Work Related
Other(s),Explain
Assessment/Diagnosis
Acute
Chronic
Confirmed
Suspected
MEDICAL PLAN
Itemized Original Invoices & Applicable Prescriptions/ Reports/ Results must be enclosed to consider the claim
Consultation
Physiotherapy
Laboratory
Radiology/Other
Pharmacy
For Almadallah's Use only
Pre-authorization Required for:
Asper agreed tariff
Full details of proposed treatment/Surgery/Medicine:
Approval Code:
IN-PATIENT
Discharge summary, Itemized Invoices, Report, 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:
Signature&Stamp
Date:
Date:
Claims should be submitted with supporting documents within 30 days from date of service or as per contract.
Patient Signature
Print
