MSH Reimbursement Claim Form

REIMBURSEMENT FORM

To help us process your claim promptly, please provide the medical report, original invoice/s and fully completed form. All documents will be handled in strict confidence by our medical team. Failure to provide the required information may result in your claim not being settled. Thank you.

1 PATIENT INFORMATION

Patient Name

Card No.

Address

Tel. No.

Fax No.

D.O.B./Age

2 BANK DETAILS (COMPULSORY)

Account Holder Name

Account Number / IBAN

Bank Name

Bank Address

Currency

UAE AED

SWIFT Code

3 MEDICAL INFORMATION (to be completed by the Physician)

Presenting symptoms

Date when symptoms first occurred

Has this or any similar condition existed previously?

Yes No

If yes, please provide details/dates*

Diagnostics / Investigations

ICD Code:

Treatments / Medications

Provisional diagnosis

4 PATIENT DECLARATION

5 PHYSICIAN DECLARATION

I hereby certify that I have personally examined and treated the insured for his/her injuries /illness described above and that the facts stated above represent my medical opinion of his/her condition.
Signature
Date

I hereby authorize the Physician, Hospital, Laboratory, Pharmacy, or any person who has provided medical services to me to furnish MSH International information with regard to any medical history, condition or services. I confirm that all information provided by myself in relation to this claim is true and correct, and no material facts have been withheld.
Signature

Date