il) i MedNet Reimbursement Form Card Holder's Name: Card No Valid Uni zune Contact Telephone: To be completed by the treating Physician ‘Dear Doctor: The beneficiary parlpaing nthe MedNet Pragram is consuing you Tor medoal cova and Kindly requests you To compe fou Diagnosis Dato of onset of symptoms Date of hospitalized ‘Admission Discharge Case Management Actual Costs Pore eee Treatment Plan Diagnostic Tests, Date Physician's Name Telephone No Physician's Stamp and Signature bate MogNet UAE FZLLC. P.O Box 500258 Dubs Internet Gay, Oubal ~ UAE Yel: +97143800710 Fax! »6714 3908600 Ema inlog@mednotuae com Web: wa mednetuae com eietly Confdential~ Contains Medical information, Not To Be Duplicated or Handled By Unauthorized PersonnelCHECKLIST oO Oo a a Completad "Reimbursement Form” Full and Complete Medical Report / Diagnosis / Discharge summary from the treating doctor FOR INPATIENT CLAIMS ONLY Original itemized invoices or receipts for the amount claimed (Invoice must show cost per service) Copies of results of diggnostic tests For treatment within UAE, please submit your ciaim within 60 days from the date of treatment For treatment outside UAE, the claim must be submitted within 80 days from the date of treatment ModNot UAE FZ LLC. 0 Box s00260 Dub srt Gy, Dubal~ UAE olss071 «se00r19 Fax 1871 43908600 E-malInbairestctuae com Webs naw mednet uae com sttcuy Contidentit~ Contains ical Information. Net To Be Duplicated or Handled By Unauthorized Personnel