dulbo @igoi Claim Form Bupa /|L9 To be completed by the membe Reese mal “Tel. / Mavite no, : Ul shad, L 209 Gold Bupa Arabia for Cooperative Insurance PO. Box 23807, Jecicah 21436, Sauci Arabia Tel: 200 244 03 07 Fax: $20 090 724 ‘wwveubupa.com.sa 1 Emergency 1 Family doctor who Sal uu Vacation / Business trip outside KSA lool aS ale Us, / Uae 1 Personal choice 1 Service not availale in network provider pa 5) $540 US Rosy pe others colease specify) wall Peeves ene re “Total amount 3 ial Medical history Diagnosis Treatment plan... Name & signature of doctor Date & stamp ‘enum or \ eT z [EFT Electronic Fue Transter) eens Name andi adaress of bank Bari account no, ‘ge gmat uals “payee name BAN ne, (asta ; SACO TT rrr rrr / i est cag yap gel datieadtd cera itt tend cami husabusdetuapgrtepeiueae dead eben carta rte ees SCR ree aan evant ae adore Signature eanre Emergency treatment outside your approved network ‘Ths bene allows you to ile for re mbursement of up co 100% ofthe actual mesical cost for all ie-threavening emergencies, Please refer to your Table of Benetits for more celal Elective treatment outside of your approved network, In oF outside of KSA, “This benett allows you to ile for re mbursement of up so 100% Of the actual medical cost baced on the veasonable anc ustorsary cost af tne same treatment Ww thin your nesworkin KSA Please refer to your Table of Benefits for more details. ‘What is Reasonable & Customary? means that the medical expenses are comparable wth the level 0” fees charges by the majorty of leensed doctors OF hospitals nthe memger's neswarien Saud Atala, aionally Rineane that she medical veatment does not sffer sign icanthy ‘rom what the Ieensed doctors consider acceptable for being ‘the usval and customary for any particular disease kn la 2 Was a osSll UES Aad Gol ye lla pall Gal nla je! 0S Sl doaaol Ua! ual \UualSl yo ajel eyo Ul sc dag dl ‘sino Ula Saal Sul 245 yiLSS otal! Use GUD Gol. who vgs lly pr BDU Go ak Siai0i \oreitall ly Sui oben! yu Wie \UuolSi Yo aad OS Ul 32) B50 63) Sey Upiell GG gate Ge Wij la) Od; yed Ladanyi) ep pina! Yul GUT Wea 98 Layo Saal eb ye LA. i a sie apes Aine Us Aaas A Sands pall Mls Lapel ye Aiea) Ot auesuiel da opie ae Yao i Maal ole All clams must include the following: 1. Original completes clan form. 2, Onignal lemized invorces and receint(s) of eayment 5. Original eval report sven 22 *Mesical- specifying siagnosis and procedure, * Dental - specifying services andl toot number + Optical- specifying iagnoss and proceaure / Eye test report from opkthalmobg st ‘orginal presertion for medicines, if applicable Photocopies of lansratory/diagnestic resorts, if apolcable Pre-authorsation orm, apotcable, recauthorisation form, for inspat ent, day case or any claim exceeding $2100. 18.For ary pencing claims, please note that missing ‘aocurmentation must be received within a maximum cet) ‘of S months (90 days), otherwise, the chim sill e automat cally rected. For treatment availed Outsice KSA! |. Copy of passaareshawing Ext & Re-enty to KSA, 2, Please retain cooies of receipts andl documents enclosed with your lar. 9 Bupa faba wll ot return the original scurments, 45.Alllaims subject to reimbursement should be submitted to ‘Bupa from the last tveatment save w thin 180 days. Note: ‘illo the above documents must be in either Englizn or Arabic language only. + Claims with comalete information/dacuments willbe processed within 10 working days tne payment selection IS'CHa or 3 working days tthe payment selection is EFT Processing time for out of kingdom claims with bles amount ‘exceeding SR 25.000 wil take up to Is working days {depending on the country where treatment took place. + Sumit your chim to Bupa = Clams Decartment, to tre following adress at 20. Box 28807, Jeddah 21456 Saud ‘Arabia or lo one of our regional branches in Rivadh {(Glesi94080) ar Khobar (03-8812230), + You may inquire about the status of your claim by calling Bua at 800 244 0507 o° email askclaims@eupa.cornsa You may algo check its status by lagging in the member's services Stour website, wwvirbupacom.sa ls of Settlement ‘Claims, { payable will be based inthe network price(s) anc standard care management ofthe same tveatrrent in your approved Bupa networkin the Kingdom of Saud Arabia, AJaike bal aninn 2gel 4 aN oS Vay las? al wha eat li Sle Ai dg ~ ak ISN + st lip aa aad) gDI— laut a + gol wai Go dal ad ys / leg sail Bp = Cyn gi © (5 lala) ays auch clog € (os eae) Sua lily Una 2 Ye 30.9 (63 laa) dag 2p) 7 Foldable tae Abige age) (ogni 9 Up ip alla usp dato wsy)Adles Oulae Sle ipa A 1 auiaal yb ala fy oy 8) patho Ladle As daa gS gat os ssh lag usie aul as a Jo ue Sa anal ap go aN ppg ay a TMF Aol ul esey obsess os gy Ua el aya Sa ag OU pa us eaihe Saa ‘ate 45 ua Ayal AU el 69S yl uns Us Ul + Use G9 Hot Carlos OU IS Cagle a aaa © USI Uae IW Use 98 god go Uwol is USI Ua pill 211 Ue Ola Asal LU Lade alg Gs ign” a SI ‘eas a9 Uae 910 URAE 99 lia isos jg 4619 OE lal Halen! 49 Ua) valley bsaless FAY Kyo Vl ign de (Win quad) Up Le linn pd eau in.) Angad =PIEP 9 (GH AAIET HY) pall £18510) Ao CEH Gna lal ole Ug le UUaiI/ elias 819 £0 ise Us Uae ay asiclaims@lbuca com saudi yy Ulu |9| ‘iS Lado ade cee Os Uganda warwbupa.comsa yu qual sil et foul yuna) tal iy 9A Una 09 Opa pass Usgzul jal Lina eSUy Gps daclzall aclu ao wie darted) For 24/7 assistance 800 244 03 07