INSURANCE, HEALTHCARE , ‘AND INVESTMENTS Healthcare Claim Form Please complete this form using block CAPITALS LETTERS and by ticking the relevant circles. You must complete sections 1,2,8 and 4. Your medical practitioner must complete sections 5 to 8. Both you and your medical practitioner must sign and date ths form, and it must be accompanied by original receipted invoices and prescriptions or it may nat processed. if you have any questions regarding ths form or any other aspects of your coverage, please telephone AXA at +4966 1-478 0282 and ask for the Healthcare Department. Please note that prior approval is required for any expenses likely to exceed SR 750. 1. Patient's details Employer | Name Pokey # fei! Patent Name Menber# qe Address PO. Box cy Postcode Contact | Phone ‘Mobile Fax Email Dateof bith [saymenwien ___/ (1 __—| When the patient fstjoined the scheme? J Pea 2.1 Payment information: Aces to whch payment shoul be sent if erent from above) 2.2. Payments il be made in Saudi Ryels ures: preagreed request a settlement by check in the order of: 2.3. youere submitting 2 claim for treatment recaved outside your area of coverage, please answer te Tolowing QuestOne 2} Country where tesiment took place ) The eeson forthe patent being abroad Dates otdeparure andveurn to Saudifraba | Deparue / Ren 24 lsme weamentaccdenteseted? %O No 25 tsk covered under ancherineurance poey? ve O noO It you answered Yes’ to tis question please gue the name of the insurance company Involved. cna seen nama’ EMC uu kok edd In which curreney was the ‘confirm tam the patient patents parent oF guardian ff patent treatment originally billed? uncer 16 years of age) and wish to claim benefit and dectare thatthe particulars given above ae to the best of my knowledge Doctor visit tue and correct. | hereby consent to and authorize the medical practioner involved n the patents care to disuss treatment details Drugs {and discharge arrangement with and to AXA Insurance. | agree aces aac megane eean ine ea cre ab, ae} ia ad ¥ x Total Please continue on the reverse page.Wereiesateree eee 5.2. Flease gue te date your pacent fist became aware of any ‘53 Pease gue the date on which yeur patent “signs oF symptoms ofthe conddons being ciamned for first presented to any doctor forthe canctten, 54 [Symptoms 7 History please give a Tul Pity OF Te mEACH COMGTUON TRIURPG VeREMEnE can RIT Ges OT AY TOUS rvestgatiorvtreatment together with relevant dats 55 [Investigations / Treatment please give fll deals of any coment lnvesigations andor reatien 56 |Drugs- crugs/othe tems presenbed 57 [Follow up peste gue detair Of ay further Weaiment planned [Name oF medical pracitoner Practice stamp Narne of patent receding weatment 6 Dental Care [to “Tooth No. Description of treatment e completed by the dentist TPRRSS TEE The oh Teed He Gaga Pease Hospital or Cine name and address arson eatrent te Saey dae fon Dacha dae way ey ) GH J ey } ERE eerste tums le | deca that lam the pavent’ medical practioner and that the paricuars gven ae to the best of my knowledge tue and correct Signature Date ¥ [dame ‘The claim form must be submitted within 60 days of the start ofthe treatment along with al orginal receipts/invokces -as per Policy membership Agreement, Ciaims will not be considered if not submitted within 2 moths of treatment being received. The issue of this ‘orm does not imply any liability on the part of AXA Insurance. Please note: You are advised to keep a record of al information supped in connection with ths Application, including any letters yhou send usin Connection witht. fyou would ike a copy of ts application, please let us know within 3 months Send this claim form together with supporting material to: Healthcare Department, AXA Insurance E.C., PO. Box 21044, Riyadh 11475, Saudi Arabia Tel: +966 1 478 0282 Fax: +966 1 477 3097 Be Life confident