GIG Gulf Reimbursement Form

Administrative Section

GIG Gulf reserves the right to request the original documents as part of processing your claims, so we strongly recommended that you retain the original documents with you for a minimum 12 months afte the date of treatment. Reimbursements will be processed in the currency your policy has been set-up in. All dependent claim reports will be directed to the contact details provided by the main member. A copy of these reports will also be sent to the main members as per the contact details provided by the Corporate Client. Please note that all reimbursement requests will be settled by bank transfer only.

Policy Number:

Membership Number:

Card Holder’s Name:

Patient Gender:

Patient's National ID/ Passport No.:

Patient's Email:

Mobile Number:

Provider Name:

Date of Treatment:

Country of Treatment:

Claimed Value/ Currency:

*** mandatory for all citizens and residents

Authorisation Statement (Please note that GIG-Gulf reserves the right to deny the claim if this section is not filled and signed)

I, the patient/GIG Gulf card holder/ Parent Patient's(incase of minor)/ Patient's Legal guardian, hereby confirm that all details and information stated in this form and all documents submitted with the claim form are complete and true. i verify that the documentation submitted electronically is true and unaltered i have all the original documents that can be presented upon request of GIG Gulf.

I hereby authorize any doctor, hospital, or medical provide, any insurance company or any other company, institution or any other person who has any record or information about me and/ or any of my family members to provide GIG Gulf with the complete information, including copies of their records with reference to my sickness or accident, any treatment, examination, advice, or hospitaliztion.

I subrogate all my rights in relation to this claim and fully authorize GIG Gulf, its representatives, affiliates to audit, review to audit, review and copy all my medical records as well as details including any historical medical records regardless of the previous payer/insurer.

I agree that any photocopy of this authorization shall be taken as the original copy.

Patient Name & Signature:

Patient's Parent Name/ Patient's Legal Guardian's**Name (incase of minor):

Parent Signature:

Legal Guardian's**Name (incase of minor):

**National ID Number:

Passport Number:

**A Legal Guardian is someone appointed by the court to manage the personal and financial affairs of another person.
*mandatory for all citizens and residents

Medical Section (to be filled by the Medical Practitioner)

I declare to be the doctor treating the patient and certify the accuracy of the information communicated and confirm that the particulars given are true to the best of my knowledge.

Doctor's Name :

Doctor's Signature and Legal Stamp :

Doctor's Phone Number :

Are you ready to submit your claim?

1. The Documents you need to submit

This claim form, duly filled and signed by you and the treting physician.

Itemised tax invoice of the received treatment(s), where applicable.

if you paid in cash> invoice must carry a 'PAID' stamp.

if you paid by card> Submit your card payment slip or statement, along with the invoice.

2. Where to submit your claim

Please visit our MyGIG Guld app or our online portal to submit your claim, track your claim status or upload any additional documents.

Disclaimer

WARNING: Any persin who knowingly, and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance polci containing ant false, incomplete or misleading information is guilty of a felony. Penalties may include but not to be restricted to denial of insurance benefits/cover, rendering the insurance contact void and/or legal action to be taken where deemed necessary.

If you have any questions regarding this form or any other aspects of the cover, please contact GIG on UAE +971 (4) 429 4000, Qatar +974 412 8733, Bahrain +973 (17) 582 612, Oman +968 800 70292, KSA +966 (1) 478 0282 quoting the policy and membership numbers. Claims must be submitting aling with supporting document within the period stipulated in your membership handbook.