Neuron Claim

Claim Form - Provider Direct Billing

Please indicate nature of claim

Medical Claim

Dental Claim

Section A - Details of Member/Patient

Patient's Name and Address

Membership Number from your card

Date of Birth

Tel Number

Fax Number

Section B - Medical Section (to be fully completed by treating physician or dentist - all boxes must be completed in block capitals)

Condition/s requiring treatment

Presenting complaint/s

History

Clinical findings

How long has the patient been aware of the complaint/s?

Date first consultation with any practitioner for this/these condition/s?

Planned treatment and prognosis

Section C - Treating Physician/Dentist

I declare that I am the patient's treating Physician/Dentist, and that the particulars given are to the best of my knowledge true and correct

Signature:

Date:

Tel Number

Fax Number

Medical Practitioner's Stamp

Other insurer's details (if the treatment is accident-related or covered under another insurance policy please provide details)

Insurance Company Name

Policy Number

Patient's Declaration and Consent

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 and declare that all the particulars given above are to the best of my knowledge true and correct. In respect of any medical claim, I hereby consent to and authorise 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. I agree that a copy of this consent shall have the validity of the original.

Signature

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. All appeals and queries regarding the claim should be submitted within 180 days of treatment. Claims will not be considered if not submitted within 90 days of treatment being received. Send this claim form together with supporting material to:
Medical Claims Department, Neuron LLC, PO Box 72071, Dubai, UAE

Claim Number (Neuron use only)