Next Care Claim

ASOAP FORM

Kindly provide the following information which will be handled with strict confidentiality by our team of doctors. Please forward this ASOAP form to: 24 hour Tel: +971 4 2708800, Fax: +971 4 2708592

(All Fields Mandatory)

ADMINISTRATIVE

Please Complete Clearly (All Fields Mandatory)

FORM No. NC:

HealthcareProvider:

Patient’sName:

Patient’sFileNo.#:

Date of Service:

Patient’s Tel:

Card No:

Patient’sEmployer:

Insurance Company:

Symptom(s) As Described by Patient (CHIEF COMPLAINT)

Date of Present Symptom Onset:

Date Symptom First Appeared:

Is the Patient under any type of treatment/Meds:

YES NO

If yes, indicate what assessment and since when:

OBJECTIVE / ASSESSMENT

Clinical Findings:

Vital Signs:BP:

T:

HR:

RR:

Assessment/Diagnosis:

INDICATE DIAGNOSIS NOT SYMPTOM:

Acute

Chronic

Confirmed

Suspected

Injury Cause

MEDICAL PLAN Itemized Original Invoices and Applicable Prescriptions / Reports / Results must be enclosed to consider claim

Is the following required?

Surgery

Endoscopy

Physiotherapy

Other procedures (if yes please specify)

For NEXtCARE use only

As per the terms of agreement and related documentation:

Approved Not Eligible

Ded:

Dhs

No. of Days:

/or Days Case:

Copar:

%

NEXtCARE Claims Center

Note: Approval Valid only for 7 days at

Is the following required?

Length of Stay

Indicate Provider

Estimated Cost

Treating Physician Name:

Tel / Fax:

Signature & Stamp:

I hereby authorize any Healthcare Provider, Insurer, Employer or other Organization to release any information regarding my medical condition & history to NEXtCARE for the purpose of determining insurance benefits

Date:

Patient’s Signature (Parent if minor)