Ne=xtcare” Allianz @) Your Health Managed vith Care eas Lyi Reimbursement Form = ity jus 310 yas! Gulla G90 Gena ee 3 aim shouldbe submited witin 30 days ofthe nal eaten date. Abas enclose the ginal voces & rec 1) Policy No: : Aad ay (1 2) Patient's Card No. apa lal uel Mala, ay (¥ 3) Policy Holder's Name: 5 aBLaatl ual (7 4) Patient's Name: aaa el ( '5) Patient's Date OF Birth: + papal adeeb (0 6) Gender: est (4 Date of Treatment: ff Date of Symptoms Onset rot I Findings : Vital Signs :8/°: T HR: 2) Cause Physical Iliness, Accident Maternity Dental Optical 3) Assessment / Diagnosis : Acute Chronic Confirmed Suspected Indicate Diagnosis not Symptoms 14) Medical Plan : Itemizad enclosed to consider claim) inal invoices and Applicable Presé ns / Reports / (results must be Consultation [ Cost Laboratory/Radiology Cost | Pharmacy | cost Inpatient Cost Total Charges 1 5) Forlnpatient Treatment; Admission date: ff Discharge Date: // Hospital / Clinic Name : Treating Physician Name Tel Fax Signature & Stamp (pops gy Atel Lat ala cel Sel jal 9b Geet | In order to ensure smooth administration of the contract . - -7 ” and/or settlement of the insurance daim, and only for that AS pB ee pes Laliey pins age! a le acts Oke as purpose, | hereby confirm that signature of this form grants, widen ie : my permission to NEXtCARE Co. to obtain all medica 21a app Ala Lal ABC le Jamal (NEXICARE) | 7H Tootion necessary forthe processing of medical claims lye elite! Qurgi RslSN LULL! | concerning myself and/or the members of my family. (elscaesile a) RA gN dole gi gaat 5 | Patient's Signature Garent mine)