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Bupa Medical Declaration Form

This document is a declaration form for a Saudi company, family, or individual to either issue a new health insurance contract, renew an existing contract, or amend an current contract number. The form requests information about the applicant such as company/family name, authorized person details, medical conditions, and confirmation that the information provided is complete and accurate. Applicants must disclose any pre-existing medical conditions and provide medical reports for review as part of the application process.

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Mhedz agao
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139 views

Bupa Medical Declaration Form

This document is a declaration form for a Saudi company, family, or individual to either issue a new health insurance contract, renew an existing contract, or amend an current contract number. The form requests information about the applicant such as company/family name, authorized person details, medical conditions, and confirmation that the information provided is complete and accurate. Applicants must disclose any pre-existing medical conditions and provide medical reports for review as part of the application process.

Uploaded by

Mhedz agao
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DECLARATION FORM

Product Type: Institutions and companies Saudi families Individual resident Domestic help

Request Type: Issue new contract Renew previous contract Amend/addition of current contract number:

Existing or previous contract ID# or membership #

Part 1: Applicant Information

Company/Institute/Family Name: Commercial Registration:

Name as it will appear on the card:

Name of the authorized person*: Gender: Male Female

Nationality: ID No.: Date of expiry:

Employer name: Job title: City:

E-mail address: Address: P.O. Box:

Telephone: Fax: Mobile: Postal code:

Preferred bank: IBAN No: S A


*This declaration form is to be filled by the insured person, the head of the family, legal representative or authorized official of the institution or company.

Part 2: Medical Declaration Part 3: List of the Patients’ Names


Please declare the presence of any of the following conditions with reference Please provide us with names of members with cases from part 2 and
in front of them. Do you have: determine the type of condition while attaching recent medical reports
Yes (not exceeding 3 months) for each condition.
1. Future plans for (Artificial / Natural) organ transplants.
2. Admission case currently in the hospital or any hospital admission
within the last 14 days or receiving treatment in emergency. Name Condition
3. Central nervous system diseases limited to: Stroke, Epilepsy.
4. Tumor or Cancer.
5. Heart conditions limited to: Arrhythmia, Ischaemic heart disease (IHD),
Open heart surgery (CABG), Catheterization, Pacemaker, Valve disease.
6. Liver disorder limited to: Hepatitis, Cirrhosis, Esophageal varices,
Gallbladder stones.
7. Urinary tract disorder limited to: Renal failure, Urinary tract stones.
8. Autoimmune disorder limited to: Ankylosing spondylitis, Multiple
sclerosis (MS), Psoriasis, Systemic lupus erythematosus (SLE),
Rheumatoid, Ulcerative colitis (Crohn's). Part 4: Confirmation and Authorisation
9. Vascular disease limited to: Phlebitis, Varicocele, Varicose vein,
Vasculitis, Aneurysm. 1. I / We confirm that all mentioned data in this form is complete
10. Blood disorder limited to: Sickle cell anemia (SCD), Hemophilia, and correct and has been discussed with all staff and their
Thalassemia, Leukemia. families in a manner not inconsistent with the privacy and
11. Congenital disorder & Hereditary disease (Diseases resulting from confidentiality of the information, and the acceptance of the
defects or genetic disorder and transmitted from one generation to application will be based on this data. Bupa Arabia for
another, or that affect the individual during fetal life) Cooperative Insurance has the right to contact the hospitals
12. Uncontrolled Diabetes / Hypertension cases needing admission from which I am / We are dealing with to provide any medical
time to time. information that may be needed to assess the risk.
13. Eye disease limited to: Cataract, Glaucoma, Corneal & Retinal condition 2. I / We agree that Bupa Arabia for Cooperative Insurance have the
14. Ear disease limited to: Hearing loss, Equilibrium problems, and Cochlear eligibility to reject the claim or the entire coverage at conceal-
problems. ment of any unexpected case or any case that arose before the
15. Bone disease limited to: Disc prolapse, Arthritis, Scoliosis, Ligament date of the contract, enrolment, or addition, even if the cases
tears, Osteoporosis. mentioned in the medical disclosure whether the cases are
16. Tissue disease limited to: Abnormal tissue growth, Cyst, Hernia, Ulcers undiagnosed before unless if there were accepted by Bupa Arabia
(Bed sores, Diabetic foot). in writing.
17. Current pregnancy for female employee or employee's wives 3. I / We undertake to perform similar declaration in the future on
18. Current multiple pregnancy or baby with congenital anomaly members who will be added during the contract period or upon
19. History of abortion or previous Cesarean section delivery or renewal as all old and new Declaration forms are considered as
instrumental assisted or premature labor or baby with congenital integral part of the current and future contracts.
anomaly.
I certify that I have read and understood all stated points in this form. I also undertake that if I didn’t tick any of the above situations then it is considered
as a denial to the existence of that declared case; and on that I sign.

Date: Signature: Stamp:

Please keep a copy of all the supplied documentation, medical records and correspondence between Bupa Arabia and yourself.

You may contact us at Toll-Free: 800 116 0500 or E-mail: [email protected]

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