Inayah Reimbursement Form

Please Use BLOCK letters to fill this form.
Please ensure that all sections are fully completed and attach all original receipt(s) showing the diagnosis and a full breakdown of cost for each condition being claimed.

Section 1 Member/Patient Information

Principal Insured Name:

Inayah Member ID No: (xxxx-x-xxxx-xxx)

Patient’s Name:

Patient’s Date of birth:

Employee No/ Staff ID: (If applicable):

Group Name (If applicable):

Principal Insured’s Tel number (mobile)

Principal Insured’s Email address

Nationality

Section 2 Medical Information

(To be fully completed by patient’s medical practitioner – all boxes must be completed in BLOCK letters.)

Country of treatment:

UAE

Provider’s name::

Physician's name:

Physician’s /telephone/ fax/ email:

Physician’s Address:

Date when first symptoms were noticed:

I declare that I am the patient’s medical practitioner, and that the particulars given are to the best of my knowledge true and correct.

Physician signature and official stamp

Date:

Diagnosis (Please provide precise diagnosis or symptom (s) and details of any test (s) conducted)

ICD Code & Name:

Section 3 Financial Section (to be completed by the Principal Insured/Guardian)

Treatments:

Total Claimed Amount and Claimed Currency:

Section 4 Bank Details

Principal Insured Name

Branch

Bank Account Holder Name

IBAN number / Account number

SWIFT code

Name of the Bank

Please recheck the Bank Account details before submission. The employee/Claimant shall be responsible for wrong bank transfers affected due to incorrect Bank details provided by him/her.

Section 5 Documents’ Submission (IMPORTANT)

Please submit the following documents in Original:

   a. Original invoices and receipts with itemized breakdown
   b. Original medical report from your treating physician
   c. Original or copies of report/result of investigations carried out
   d. Complete Reimbursement Claim Form
   e. Discharge Summary and copy of prior approval (for inpatient cases only)

**NOTE: INAYAH pre-approval is required for all In-patient treatment. Before admission/surgery, you are required to send to INAYAH a detailed medical report and cost estimate of the proposed surgical procedure/treatment on the letterhead of the hospital with affixed physician's stamp and signature along with the result of relevant investigations carried out and e- mail it to approvals@inayahtpa.com. Thereafter, you shall receive a reply from INAYAH regarding reimbursement coverage.

All Documents must be submitted in English or Arabic, documents in other languages must be translated prior to submission.

Section 6 Patient’s Declaration and Consent

I confirm I am the patient/patient’s spouse or guardian (if patient is under 18 years of age) claim benefits and declare that all the particulars given above are to the best of my knowledge true and correct. In addition, I, the undersigned, authorize and request any hospital, physician, and any other health provider to furnish INAYAH TPA LLC with the complete information including copies of their records in connection with medical treatment or other services provided to me or to my dependent.

I agree that a copy of this consent shall have the validity of the original

Signature of the Patient/Patient’s Spouse /Guardian and wish to

Date :