Oman Claim

Medical Authorization Centre: 800 6626 General Inquiries: 800 4746

Outpatient Claim Form

Direct Billing - Healthcare Insurance

One Claim Form per person

Section 3 & 4 to be filled by treating doctor & Section 5 by patient. All other sections to be filled by Administrative Personnel. Please write in BLOCK LETTERS. In case additional details need to be provided, please photocopy this sheet.

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1.Provider Details

Claim Form Number:

Provider Name

Facility License Code

2. Member/Patient Details

Card Number

Date of Birth(dd/mm/yyy)

Patient’s Name (as it appears on the card)

Telephone Number

Gender

Medical Record Number

Reason for Visit

Emergency

Road traffic accident

Work related accident

New visit

Follow up

Referral

Referral source

3. Medical Section

Chief complaint & duration

First consultation date for above condition (dd/mm/yyyy

Initial Diagnosis

Please tick theappropriatebox

Maternity

Acute

Chronic

Congenital

If maternity related, please indicate LMP

How long patient is aware of the complaint?

Final Diagnosis

ICD Code(s)

TreatmentDetails

CPT Code(s)

Pre authorisation

4. Doctor’s Declaration

I declare that I am the patient’s treating doctor and the particulars given are trueand correct to the best of my knowledge

Doctor’s Stamp

Signature

Date

5.Patient’sDeclaration

I confirm that all particulars above are true. I hereby authorize (i) the medical provider and any other entity to provide and discuss health/treatment details with Oman Insurance Companyand/or thirdparty administrator(ii)Oman InsuranceCompany to (a)disclose my personal/claim information for claimprocessing or as may be required(b)contact me for claim/other products information.I agree that a copy of this consent shall have the validity of original.

Name

Signature

Date

OmanInsuranceCompany(P.S.C.),PaidupCapital461,872,125,C.R.No.41952,InsuranceAuthorityNo.9dated24/12/1984HeadOffice:P.O.

Box5209,Dubai,UnitedArabEmirates.Tel:+97142337777,Fax:+97142337775,www.tameen.ae