Scribd Logo
Upload

Welcome to Scribd!

  • 214 views

    Reimbursement Form: To Be Completed by The Treating Physician

    Uploaded by

    rthomsan
    This reimbursement form is for a patient covered by the MedNet program. It requests information from the treating physician including diagnosis, date symptoms began, hospitalization details if applicable, actual costs, treatment plan, and diagnostic tests and pharmaceuticals prescribed. The physician must sign and stamp the form, which is then submitted to the insurance company within 30 days for local treatment or 60 days for overseas treatment for reimbursement processing in accordance with the patient's insurance plan. The form also provides contact information for notifying the insurance company of planned elective admissions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Reimbursement Form: To Be Completed by The Treating Physician

    Uploaded by

    rthomsan
    214 views2 pages
    This reimbursement form is for a patient covered by the MedNet program. It requests information from the treating physician including diagnosis, date symptoms began, hospitalization details if applicable, actual costs, treatment plan, and diagnostic tests and pharmaceuticals prescribed. The physician must sign and stamp the form, which is then submitted to the insurance company within 30 days for local treatment or 60 days for overseas treatment for reimbursement processing in accordance with the patient's insurance plan. The form also provides contact information for notifying the insurance company of planned elective admissions.

    Original Description:

    Form

    Original Title

    Form I23

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This reimbursement form is for a patient covered by the MedNet program. It requests information from the treating physician including diagnosis, date symptoms began, hospitalization details if applicable, actual costs, treatment plan, and diagnostic tests and pharmaceuticals prescribed. The physician must sign and stamp the form, which is then submitted to the insurance company within 30 days for local treatment or 60 days for overseas treatment for reimbursement processing in accordance with the patient's insurance plan. The form also provides contact information for notifying the insurance company of planned elective admissions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    214 views2 pages

    Reimbursement Form: To Be Completed by The Treating Physician

    Uploaded by

    rthomsan
    This reimbursement form is for a patient covered by the MedNet program. It requests information from the treating physician including diagnosis, date symptoms began, hospitalization details if applicable, actual costs, treatment plan, and diagnostic tests and pharmaceuticals prescribed. The physician must sign and stamp the form, which is then submitted to the insurance company within 30 days for local treatment or 60 days for overseas treatment for reimbursement processing in accordance with the patient's insurance plan. The form also provides contact information for notifying the insurance company of planned elective admissions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Reimbursement Form

    Card Holder’s Name: Card No.:


    Valid Until: Contact Telephone:
    To be completed by the treating Physician
    Dear Doctor: The beneficiary participating in the MedNet Program is consulting you for medical care and kindly requests you to complete this
    form.

    Diagnosis :

    :
    Date of onset of symptoms
    :

    If, hospitalized Date of Admission Discharge


    :

    Case Management

    Actual Costs
    :

    Treatment Plan
    Diagnostic Tests Pharmaceuticals

    Date Cardholder’s signature

    Physician’s Name

    Telephone No.
    Physician’s Stamp and Signature
    Date
    Saudi National Insurance Co.
    P.O. Box 31516, Manama – Kingdom of Bahrain
    Tel.: +973 17 56 33 77 Fax: +973 1756 42 43 E-mail: [email protected]

    Strictly Confidential – Contains Medical Information. Not To Be Duplicated or Handled By Unauthorized Personnel
    CHECKLIST

    Completed “Reimbursement Form”

    Full and Complete Medical Report / Diagnosis / Discharge summary from the treating doctor

    Original itemized invoices or receipts for the amount claimed (Invoice must show cost per service)

    Personalized SOAP / Maternity SOAP / Dental SOAP (if applicable)

    Copies of results of diagnostic tests

    For treatment within Bahrain, please submit your claim within 30 days from the date of treatment. For treatment outside Bahrain,
    the claim must be submitted within 60 days from the date of treatment.

    Kindly note that eligible medical expenses rendered outside MedNet Bahrain’s provider network will be reimbursed in
    accordance with the relevant plan chosen and not at cost incurred.

    IN-HOSPITAL NON- EMERGENCY ADMISSION

    The MedNet Bahrain Call Centre should be notified, at least 7 days in advance for arranging elective treatment on free access basis
    at a network facility outside Bahrain, if applicable.

    Within Bahrain (24 hours a day, 7-days a week)

    Toll Free Phone - 8000 1113

    Outside Bahrain (24 hours a day, 7- days a week)

    Phone +973 175 66 888


    Fax +973 175 83 009

    Saudi National Insurance Co.


    P.O. Box 31516, Manama – Kingdom of Bahrain
    Tel.: +973 17 56 33 77 Fax: +973 1756 42 43 E-mail: [email protected]

    Strictly Confidential – Contains Medical Information. Not To Be Duplicated or Handled By Unauthorized Personnel

    You might also like