Claim Expense Form (Medical, Dental, Vision) printable pdf download

CLAIM EXPENSE FORM

(Medical, Dental, Vision)

A. EMPLOYEE’S SECTION

Member No.: ___________________ Employee No.: ________________________ Birth date: _______________________

Patient Name: _________________________________________ State Nature of Illness: ___________________________

Country of Treatment: ___________________________________ Date of Treatment: ______________________________

Pay to (Name): ________________________________________ Email address: _________________________________

Bank Account No: _____________________________________ Bank Name: ___________________________________

Mailing Address: _____________________________________________________________________________________

(Settlement cheque will be deposited where possible or will be mailed to this address)

Authorization: I the undersigned, hereby certify that all

BREAKDOWN OF EXPENSES

CURRENCY:

answers and all documents submitted with this Claim form are

(compulsory)

complete and true. I hereby authorize any doctor, hospital,

clinic or medical provider, any insurance company or any other

company, institution or any other person who has any record

Dr’s FEES (consultation)

or any information about me and/or any of my family members

to provide SAICO with the complete information, including

MEDICINES

copies of their records with reference to any illness, accident,

treatment, examination, advice or hospitalization. A photocopy

OTHERS (lab, X-Rays, dental,

of this authorization shall be taken as the original.

vision, etc)

TOTAL AMOUNT CLAIMED:

Member’s signature: __________________ Date: _________________ Contact No.: _______________________________

B. PHYSICIAN’S SECTION

Patient name (CAPITALS): _________________________________________________________ Age: ______________

Diagnosis (CAPITALS): ____________________________________________________________ ICD: ______________

Type of treatment: [

] Illness

Date first seen _____________ _______

[

] Accident

Work Related YES / NO Date: _____________________ Time: _____________

Cause: ________________________________ Place: ____________________

[

] Pregnancy

Date of LMP: _________________ Expected delivery date: _________________

[

] Hospitalization Date admitted:_________________ Date discharged: ______________________

PHYSICIAN’S DECLARATION: I certify that the Medical services shown on this form were medically indicated and necessary

for the health of the patient.

Physician’s Stamp: ______________________________ Signature: _____________________ Date: _________________

C. ATTACHMENTS REQUIRED

1. Invoices with proof of payment.

2. Doctor’s prescription for medicines, lab tests, X-rays etc.

3. Pharmacy invoice clearly showing name of medicine, quantity purchased and price of each medicine.

4. Copy of patient’s SAICO membership card.

P.O.Box 58073, Riyadh 11594, Saudi Arabia –Phone: (9661) 4751167 Fax: (9661) 4751168 Email:

.sa

Claim Expense Form (Medical, Dental, Vision)

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