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    Mednet RI Form

    Uploaded by

    hhmoud

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Mednet RI Form

    Uploaded by

    hhmoud
    4 views2 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    4 views2 pages

    Mednet RI Form

    Uploaded by

    hhmoud

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    MedNet UAE FZ L.L.C.

    Reimbursement Form

    Card Holder’s Name: Husam Alhmoud Card No.: 097110040341150801

    Valid Until: 14-Mar-2024 Contact Telephone: +971 55 5533106

    To be completed by the treating Physician


    Dear Doctor: The beneficiary participating in the MedNet Program is consulting you for medical care and kindly requests you to complete this
    form.

    Diagnosis : DJ stent removal

    Date of onset of symptoms :

    : Date of
    If, hospitalized Admission Sep 12, 2024 Discharge Sep 12, 2024

    :
    Case Management

    Actual Costs
    : JOD 722

    Treatment Plan
    Diagnostic Tests Pharmaceuticals

    Sep 27, 2024


    Date Cardholder’s signature

    Physician’s Name

    Telephone No.

    Physician’s Stamp and Signature


    Date

    P.O. Box 500259, Dubai Internet City, Dubai – UAE


    Tel.: +971 4 3900710 Fax: +971 4 3908600
    E-mail: [email protected] Web: www.mednet-uae.com

    Strictly Confidential – Contains Medical Information.


    Not To Be Duplicated or Handled By Unauthorized Personnel
    MedNet UAE FZ L.L.C.

    CHECKLIST

    Completed “Reimbursement Form”

    Full and Complete Medical Report / Diagnosis / Discharge summary from the treating doctor

    Original itemized invoices or receipts for the amount claimed (Invoice must show cost per service)

    Personalized SOAP / Maternity SOAP / Dental SOAP (if applicable)

    Copies of results of diagnostic tests

    For treatment within UAE, please submit your claim within 60 days from the date of treatment. For treatment
    outside UAE, the claim must be submitted within 90 days from the date of treatment.

    IN-HOSPITAL NON- EMERGENCY ADMISSION

    The MedNet Claims Centre should be notified, at least 7 days in advance for arranging elective treatment on free
    access basis at a network facility outside UAE, if applicable.

    Within UAE (24 hours a day, 7-days a week)

    Toll Free Phone - 800 4882


    Toll Free Fax - 800 4883

    Outside UAE (24 hours a day, 7- days a week)

    Phone - 00 971 4 3900749


    Fax - 00 971 4 3908598

    P.O. Box 500259, Dubai Internet City, Dubai – UAE


    Tel.: +971 4 3900710 Fax: +971 4 3908600
    E-mail: [email protected] Web: www.mednet-uae.com

    Strictly Confidential – Contains Medical Information.


    Not To Be Duplicated or Handled By Unauthorized Personnel

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