GIG Insurance UAE I Direct Billing Claim Form I Medical Providers
Administrative Section
Policy number
Membership number
Patient name
Provider name
Date of treatment
Patient Gender
Medical Section
Type of visit
Outpatient
Inpatient
Emergency
Maternity
Dental
Optical
If pregnant: L.M.P. Date
Nature of conception
Natural
Assisted
Chief complaint
History of present illness
Clinical findings/other conditions
Past medical history
Details of trauma - if applicable (where, when & how)
Work Related
RTA Related
Sports Related
If yes
Professional
Non-professional
Diagnosis
Treatment plan, recommended medications, investigations, and/or procedures
Patient declaration
I hereby confirm that I am the patient/GlG cardholder, Patient's parent or guardian (if under 16 years of age) and I wish to claim and declare that all the details/ information given above are to the best of my knowledge true and correct. I hereby consent to and fully authorize the medical practitioner involved in the patient's care to discuss treatment details and discharge arrangements with and to GIG Insurance (Gulf) B.S.C representative or any of AXA company affiliates. I subrogate all my rights in relation to this claim and I fully authorize and give access to AXA Insurance (Gulf) B.S.C © representative or any of AXA company affiliates to audit, review and copy all my medical records details including any historical medical records regardless the previous payer/insurer. I agree that a copy of this consent shall have the validity of the original.
I hereby confirm that I am the patient/GlG cardholder, Patient's parent or guardian (if under 16 years of age) and I wish to claim and declare that all the details/ information given above are to the best of my knowledge true and correct. I hereby consent to and fully authorize the medical practitioner involved in the patient's care to discuss treatment details and discharge arrangements with and to GIG Insurance (Gulf) B.S.C representative or any of AXA company affiliates. I subrogate all my rights in relation to this claim and I fully authorize and give access to AXA Insurance (Gulf) B.S.C © representative or any of AXA company affiliates to audit, review and copy all my medical records details including any historical medical records regardless the previous payer/insurer. I agree that a copy of this consent shall have the validity of the original.
Medical practitioner declaration
declare that I am the patient's medical practitioner, and that the particulars given are to the best of my knowledge true and correct.
Date
Stamp
declare that I am the patient's medical practitioner, and that the particulars given are to the best of my knowledge true and correct.
Date
Stamp
WARNING:Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Penalties may include but not be restricted to denial of insurance benefits / cover, rendering the insurance contract void and/or legal action to be taken where deemed necessary.
If you have any questions regarding this form or any other aspects of the cover, please contact GIG on UAE +971 (4) 429 4000, Qatar +97 4 412 8733, Bahrain +973 (17) 582 612, KSA +966 (1) 478 0282 quoting the policy and membership numbers. Claims must be submitted along with supporting documents with•n 30 days from date of serv•ce. Send this claim form together with supporting material to Medical Department, GIG Insurance, PO BOX 32505, Dubai, UAE or GIG nsurance, P.O. Box 45, Kingdom of Bahrain or GIG Insurance PO BOX 21044, 11475 Riyadh, Kingdom of Saudi Arabia or GIG Insurance, PO Box 15319, Doha, State of Qatar.