AUTHORIZATION FORM

№:AS12035
On Behalf of the Payer: Assurex
Provider Name: Clinilab Officer Name: Mariana Bachour
Attention: Admission Department Division: Claims Center
Fax No:

Date: 21-02-2022 Validity of this authorization is One Week from this authorization date

PATIENT INFORMATION
Patient Name: GRETTA HNEIN Date of Birth: : 09-Jun-1983
Policy No: HG-00100831 Expiry Date :under processing
Policy Holder: 1797351 Card No3A12-184B-7086-99CA
Product: GRS GN- IN-NSSF, AMB 15%(Tob2)-A Priority Payer:

MEDICAL INFORMATION
Physician Name Chadi Fakih Family of Benefits: OUT
Physician Specialty: Gyn Prescription Motive: Maternity
Consultation Date: 14-02-2022 Admission date: 21-02-2022
Length of Stay: 0

AUTHORIZATION NOTES
Admission Class : OUT
Treatment:
CBC, Toxo IGG/IGM, Rubella IGG/IGM, Urine analysis, TSH, Vit D, Coombs indirect

REMARKS:
To cash 15 % from the patient
Bill will be paid in Fresh USD

DISCLAIMER
1. NEXtCARE will only approve medical charges directly and strictly related to the case registered above. The final bill shall remain subject to billing rules, and to
our auditing doctors’ approval.
2. NEXtCARE hereby clearly reserves the right to decline any claim settlement due to misuse, abuse or tentative of fraud related either to the entry of the
aforementioned information or to its trueness.
3. Copy of this authorization form should be attached to the claim on submission for reimbursement.
4. If you have any questions or require further information, please contact NEXtCARE Claim Center on tel. 01-504000 or fax on 01-498323, 24 hours a day.
5. This form is subject to the terms, conditions, and procedures of the contract signed with NEXtCARE.

Best Regards,
NEXtCARE