CHRONIC CLAIM

FORM

Insured’s Name Employee # Contract Number

Insurance Co Mobile # Individual Number

Date of Visit CID # Policy Holder

(To be completed by the Attending Physician)

Doctor’s Name Mobile # Specialty

DURATION OF DISEASE

CHIEF COMPLAINTS

TREATMENT PLAN

Medicine Name Allowed Generic Substitute Dose Frequency Duration

I the undersigned, hereby declare the following: I give full authorization to the I hereby certify that ALL information mentioned
Insurance Company and/or employer adhering to GlobeMed and its representatives to are correct & that the medical services shown
inquire about my past and actual state of health. I also authorize them to inform my on this form were medically indicated &
attending physician, within their capacities, of the information available at their end necessary for the management of this case.
about my state of health. Hence, I request from the healthcare provider to reveal and
provide the Insurance Company and/or employer and GlobeMed and its representatives, Dr.
with all available information concerning my person that are known to them or that are
held in their files and medical records and photocopies of it. Physician SIGNATURE & STAMP

NAME SIGNATURE

DATE ____ / ____ / ____

DOCUMENTS NEEDED
FOR REIMBURSEMENT CLAIMS

DOCUMENTS NEEDED FOR DOCTOR VISIT, ‫المستندات المطلوبة إلعادة تسديد زيارة الطبيب‬
AMBULATORY TESTS AND HOSPITALIZATION ‫والفحوصات الخارجية وحاالت االستشفاء داخل المستشفى‬
REIMBURSEMENT CLAIMS
‫ تقرير طبي مفصل موقع ومختوم من قبل الطبيب المعالج يشرح‬.1
1. Detailed Medical Report signed and stamped by the ‫ بداية ظهور‬،‫ شكوى المريض‬،‫وضع المريض الصحي (التشخيص‬
treating physician (Diagnosis, complaints, past medical ‫ التاريخ المرضي السابق و اي حاالت‬،‫االعراض او الحالة المرضية‬
history, duration of illness and other conditions). )‫اخرى‬
.‫ فاتورة اصلية مفصلة محدد فيها سعر كل خدمة مقدمة‬.2
2. Detailed original invoice i.e. cost per item.
‫ نتائج التحاليل المخبرية واالشعة وتحاليل االنسجة (الباثلوجيا‬.3
3. Results for all tests done e.g. labs, radiology, .‫الخ‬... )‫الخلوية‬
cytopathology... etc.
‫ التقرير النهائي عند خروج المريض من المستشفى (فقط في حالة‬.4
4. Discharge summary for in-patient cases. )‫االقامة داخل المستشفى للحاالت المرضية او الجراحية‬

DOCUMENTS NEEDED FOR PRESCRIPTION MEDICINE ‫المستندات المطلوبة إلعادة تسديد األدوية موضوع‬
REIMBURSEMENT CLAIMS ‫وصفة طبية‬

1. Original prescription or a stamped copy of the ‫ الوصفة األصلية أو صورة مختومة بخاتم الصيدلية في حالة‬.1
prescription in case the prescribed medicines are .‫وصفات المضادات الحيوية ومركبات الكورتيزول‬
antibiotics or steroids.
.‫ فاتورة اصلية مفصلة محدد فيها سعر كل دواء‬.2
2. Detailed original invoice i.e. cost per item.

DOCUMENTS NEEDED FOR DENTAL TREATMENT ‫المستندات المطلوبة إلعادة تسديد‬

REIMBURSEMENT CLAIMS ‫عالج االسنان‬

1. Panoramic X-ray .)Panoramic( ‫ األشعة السنية‬.1

2. Detailed original invoice i.e. cost per item. .‫ فاتورة اصلية مفصلة محدد فيها سعر كل خدمة مقدمة‬.2

A copy of the insurance card and the Civil ID should ‫يجب ان يرفق مع كل طلب صورة عن بطاقة التأمين‬
be enclosed. .‫والبطاقة المدنية‬
PAYMENT
DETAILS

Have you personally had to pay costs for the treatment that you are claiming for? Yes No

If yes, and you are personally seeking reimbursement, please tell us how you wish to be reimbursed (Please tick one):

1- Bank transfer. Please fill in this information for bank transfer payments: (Please note that this is the quickest and safest method of payment)

Name of account holder

Name of your bank Account number

Address for your bank

IBAN number

Routing code / swift code / sort code Currency of bank account

2- Foreign draft. Please tell us what currency

MEMBER’S DECLARATION

I declare that all the details given on this claim form are true and accurate and that I have not missed out any details important to this claim. I understand
that if this claim is found to be fraudulent, in whole or part, I am committing a criminal offence and that this will invalidate the plan and make me
liable to prosecution. For this medical claim I authorise any medical practitioner, specialist, consultant, therapist or other relevant establishment who
has attended me/the patient in the past or is attending me/the patient at present, to give any details that may be asked for by Insurance Company/
GlobeMed. I confirm and agree that any personal information collected or held by Insurance Company/GlobeMed, whether given on this form or collected
in any other way, may be used by Insurance Company/GlobeMed or disclosed to or transferred to any organisation for the purpose of i) assessing this
claim and giving on-going insurance cover, customer service and the processing of future claims, ii) processing and making payments, iii) providing
marketing communications in respect of Insurance Company/GlobeMed, its related products and services and those of its associated companies.

Member’s Signature

Date (dd/mm/yy)