0% found this document useful (0 votes)

711 views1 page

'NEXtCARE Egypt - Reimbursement Form

This document is a reimbursement form for healthcare expenses. It requests information about the patient, provider, and treatment. The form is divided into administrative, subjective, and objective sections. The administrative section requests identifying information. The subjective section is for the patient's reported symptoms. The objective section is for the physician's assessment, including diagnosis, treatment plan, and total charges. The form requires the patient's signature authorizing release of medical information to the insurance provider.

Uploaded by

Mohyee Eldin Rageb

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

0% found this document useful (0 votes)

711 views1 page

'NEXtCARE Egypt - Reimbursement Form

Uploaded by

Mohyee Eldin Rageb

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

You are on page 1/ 1

REIMBURSEMENT FORM

24 hour Tel: 920003055, Fax: +966-13-8988940

Please Complete Clearly (All Fields Mandatory) FORM No:

ADMINISTRATIVE
Healthcare Provider: Patient’s Name:
Date of Service: dd /mm /yyyy Patient’s Tel: DOB dd/mm/yyyy Sex: ☐ F ☐ M
Email address:
Emirates ID No:
(Mandatory)
Insurance Company:
Account Name: EGYPT IBAN Number:
EGYPT Bank Name: EGYPT Swift Code:
SUBJECTIVE (To be completed by Physician)
Symptom(s) As Described by Patient (CHIEF COMPLAINT)

Date of Present Symptom Onset: / / __

dd mm yyyy

What date did the Patient first feel same / similar symptom(s): ______ / ________ / ________
dd mm yyyy
Is the Patient under any type of treatment / Meds: ☐YES ☐ NO
If yes, indicate what assessment and since when:

OBJECTIVE / ASSESSMENT (To be completed by Physician) Vital Signs T: P: R: B/P:

Past Medical & Surgical History:
Clinical Details & Description of Present Case:
Cause: ☐Physical Illness ☐Accident ☐Maternity ☐Preventive ☐Psychiatric ☐Dental ☐Work Related
☐Acute ☐Chronic ☒Confirmed ☐Suspected ☐Other
Assessment / Diagnosis: INDICATE DIAGNOSIS NOT SYMPTOM Diagnosis Code
1.
2.
3.
Is Assessment / Diagnosis related to another Assessment? ☐ YES ☐ NO If yes, specify: (i.e. Retinopathy
related to Diabetes
MEDICAL PLAN Itemized Original Invoices and Applicable Prescriptions / Reports / Results must be enclosed to consider claim
☐ Consultation Cost ☐ Physiotherapy Cost

☐ Pharmacy Cost ☐ Laboratory / Radiology / Other Cost

TOTAL CHARGES
Was In-patient Required? Length of Stay___________________________ Indicate Provider___________________________ Cost
_______________
 Discharge Summary: Itemized Invoices, Reports & Receipts Attached?
Treating Physician Name: I hereby authorize any Healthcare Provider, Insurer, Employer
or other Organization to release any information regarding my
Name & Address of Facility: medical condition & history to NEXtCARE for the purpose of
determining insurance benefits.
Tel / Fax:
Email:
Signature & Stamp: Patient’s Signature (Parent if minor) Date