10/07/2020

Explanation of Benefits
Risk Carrier : ALEXANDRIA BANK SFS Policy Holder Name : ALEX BANK SFS
Member : 50009604 50769011 Staff # : 10198 Provider : Al Borg Laboratories - Minia
Claim Number :
MCN : 30812456 Batch # : 0
Principal Name : ‫ﻡ ﻋﺒﺪ ﺍﺣﻤﺪ‬
Name : ‫ﺍﺣﻤﺪ ﻋﺒﺪ‬
Date Of Birth : 1983

Transaction Date : 10/07/2020 Invoice Number : Physician : Default Doctor

Diagnosis : Non-insulin-dependent diabetes mellitus without complications Approved by

Essential (primary) hypertension

Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 38378643

Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc.

LABORATORY 1- "Lipid Profile(Chol,Tri,HDL,LDL)" 147.000 1 EGP 147.000 1 147.000 14.700

2- Random Blood Glucose 21.000 1 EGP 21.000 1 21.000 2.100

3- Haemoglobin A1C 89.250 1 EGP 89.250 1 89.250 8.925

Summary Patient Share

Total Claimed 257.250 EGP Co-Insurance 0.000 EGP
Total Approved 257.250 EGP Exceeding Limitation 0.000 EGP
Discount 25.725 EGP Uncovered Items 0.000 EGP

Net Amount 231.525 EGP Total Patient Share 0.000 EGP

The claims will be subject to review and audit based on the Tariff, Discounts and Medical Necessity (Usual, Reasonable and Customary), on case by case basis. Thank You. Page 1 of 1