Self Assessment
Mednet Claim
MedNet Global Healthcare Solutions L.L.C.
Paid-up capital AED 5,000,000
MEMBER DETAILS
MEMBER NAME:
INSURANCE PLAN
DHA MEMBER ID
EID
DOB
CARD NUMBER
GENDER
MOBILE NUMBER
START DATE
MEMBER NETWORK
END DATE
BENEFIT DETAILS
Please follow benefits list for other deductible/copayment details
PRE-APPROVAL PROTOCOL: All services require prior-approval. Please proceed with services only with approval.
SUBJECTIVE
OBJECTIVE
TEMP:
PR:
RR:
BP:
WEIGHT:
P
L
A
N
PHARMACEUTICALS
P
L
A
N
DIAGNOSTIC PROCEDURES
Facility Name:
Patient Registered by:
Telephone No:
Date and Time:
Physician's Name:
Physician's Stamp and Signature:
Card Holder’s Signature:
"I hereby authorize any MedNet personnel to access my medical file"
DISCLAIMER:
ALL SERVICES OUTSIDE PRE-APPROVAL PROTOCOL ARE SUBJECT TO RESTROSPECTIVE MEDICAL EVALUATION UPON CLAIM SUBMISSION. CLAIMS PROCESSING IS SUBJECT TO CONTRACTUAL TARIFF.
MedNet Claims Center: 600 546002 (24-hour hotline), Fax: 800 4883
E-mail: mcc@mednet.com
Contains Confidential Medical Information. Not To Be Handled By Unauthorized personnel
Patient Signature
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