"Medical, Dental, Vision Claim Expense Form - Saico" - Riyadh Region, Saudi Arabia

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Download "Medical, Dental, Vision Claim Expense Form - Saico" - Riyadh Region, Saudi Arabia

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CLAIM EXPENSE FORM
(Medical, Dental, Vision)
A. EMPLOYEE’S SECTION
Member No.: ___________________ Employee No.: ________________________ Birth date: _______________________
Patient Name: _________________________________________ State Nature of Illness: ___________________________
Country of Treatment: ___________________________________ Date of Treatment: ______________________________
Pay to (Name): ________________________________________ Email address: _________________________________
Bank Account No: _____________________________________ Bank Name: ___________________________________
Mailing Address: _____________________________________________________________________________________
(Settlement cheque will be deposited where possible or will be mailed to this address)
Authorization: I the undersigned, hereby certify that all
BREAKDOWN OF EXPENSES
CURRENCY:
answers and all documents submitted with this Claim form are
(compulsory)
complete and true. I hereby authorize any doctor, hospital,
clinic or medical provider, any insurance company or any other
company, institution or any other person who has any record
Dr’s FEES (consultation)
or any information about me and/or any of my family members
to provide SAICO with the complete information, including
MEDICINES
copies of their records with reference to any illness, accident,
treatment, examination, advice or hospitalization. A photocopy
OTHERS (lab, X-Rays, dental,
of this authorization shall be taken as the original.
vision, etc)
TOTAL AMOUNT CLAIMED:
Member’s signature: __________________ Date: _________________ Contact No.: _______________________________
B. PHYSICIAN’S SECTION
Patient name (CAPITALS): _________________________________________________________ Age: ______________
Diagnosis (CAPITALS): ____________________________________________________________ ICD: ______________
Type of treatment: [
] Illness
Date first seen _____________ _______
[
] Accident
Work Related YES / NO Date: _____________________ Time: _____________
Cause: ________________________________ Place: ____________________
[
] Pregnancy
Date of LMP: _________________ Expected delivery date: _________________
[
] Hospitalization Date admitted:_________________ Date discharged: ______________________
PHYSICIAN’S DECLARATION: I certify that the Medical services shown on this form were medically indicated and necessary
for the health of the patient.
Physician’s Stamp: ______________________________ Signature: _____________________ Date: _________________
C. ATTACHMENTS REQUIRED
1. Invoices with proof of payment.
2. Doctor’s prescription for medicines, lab tests, X-rays etc.
3. Pharmacy invoice clearly showing name of medicine, quantity purchased and price of each medicine.
4. Copy of patient’s SAICO membership card.
P.O.Box 58073, Riyadh 11594, Saudi Arabia –Phone: (9661) 4751167 Fax: (9661) 4751168 Email:
saicome@saico.com.sa
CLAIM EXPENSE FORM
(Medical, Dental, Vision)
A. EMPLOYEE’S SECTION
Member No.: ___________________ Employee No.: ________________________ Birth date: _______________________
Patient Name: _________________________________________ State Nature of Illness: ___________________________
Country of Treatment: ___________________________________ Date of Treatment: ______________________________
Pay to (Name): ________________________________________ Email address: _________________________________
Bank Account No: _____________________________________ Bank Name: ___________________________________
Mailing Address: _____________________________________________________________________________________
(Settlement cheque will be deposited where possible or will be mailed to this address)
Authorization: I the undersigned, hereby certify that all
BREAKDOWN OF EXPENSES
CURRENCY:
answers and all documents submitted with this Claim form are
(compulsory)
complete and true. I hereby authorize any doctor, hospital,
clinic or medical provider, any insurance company or any other
company, institution or any other person who has any record
Dr’s FEES (consultation)
or any information about me and/or any of my family members
to provide SAICO with the complete information, including
MEDICINES
copies of their records with reference to any illness, accident,
treatment, examination, advice or hospitalization. A photocopy
OTHERS (lab, X-Rays, dental,
of this authorization shall be taken as the original.
vision, etc)
TOTAL AMOUNT CLAIMED:
Member’s signature: __________________ Date: _________________ Contact No.: _______________________________
B. PHYSICIAN’S SECTION
Patient name (CAPITALS): _________________________________________________________ Age: ______________
Diagnosis (CAPITALS): ____________________________________________________________ ICD: ______________
Type of treatment: [
] Illness
Date first seen _____________ _______
[
] Accident
Work Related YES / NO Date: _____________________ Time: _____________
Cause: ________________________________ Place: ____________________
[
] Pregnancy
Date of LMP: _________________ Expected delivery date: _________________
[
] Hospitalization Date admitted:_________________ Date discharged: ______________________
PHYSICIAN’S DECLARATION: I certify that the Medical services shown on this form were medically indicated and necessary
for the health of the patient.
Physician’s Stamp: ______________________________ Signature: _____________________ Date: _________________
C. ATTACHMENTS REQUIRED
1. Invoices with proof of payment.
2. Doctor’s prescription for medicines, lab tests, X-rays etc.
3. Pharmacy invoice clearly showing name of medicine, quantity purchased and price of each medicine.
4. Copy of patient’s SAICO membership card.
P.O.Box 58073, Riyadh 11594, Saudi Arabia –Phone: (9661) 4751167 Fax: (9661) 4751168 Email:
saicome@saico.com.sa