Direct Billing Form - KSA

DIRECT BILLING CLAIM

Direct billing claim form

Direct Billing Claim Form

This claim form is not an admission of liability.

1542972163677

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Administrative Section

Policy Number

Membership Number

Patient Name

Provider Name

Date of treatment

Patient Gender

Male

Female

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Medical Section

If Pregnant: L.M.P. Date

Nature of Conception:

Natural

Assisted

Chief complaint

History of present illness

Clinical findings / Other conditions

Past medical history

Details of trauma - if applicable (when, where & how)

Work related

RTA related

Sports related

If yes:

Professional

Non-Professional

Diagnosis

Treatment plan, recommended medications, investigations, and/or procedures

Patient declaration

I hereby confirm that I am the patient/AXA card holder, Patient's parent or guardian (ifunder 16 years of age) and I wish to claim and declare that all the details/ informationgiven above are to the best of my knowledge true and correct. I hereby consent to andfully authorize the medical practitioner involved in the patient's care to discusstreatment details and discharge arrangements with and to AXA Insurance (Gulf) B.S.C© representative or any of AXA company affiliates. I subrogate all my rights in relationto this claim and I fully authorize and give access to AXA Insurance (Gulf) B.S.C ©representative or any of AXA company affiliates to audit, review and copy all mymedical records details including any historical medical records regardless theprevious payer/insurer. I agree that a copy of this consent shall have the validity of theoriginal.

Signature Date

Medical practitioner declaration

I declare that I am the patient's medical practitioner, and that the particulars given areto the best of my knowledge true and correct.

Name Signature Date Stamp

WARNING:Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policycontaining any false, incomplete or misleading information is guilty of a felony. Penalties may include but not be restricted to denial of insurance benefits /cover, rendering the insurance contract void and/or legal action to be taken where deemed necessary.

If you have any questions regarding this form or any other aspects of the cover, please contact AXA on UAE +971 (4) 429 4000, Qatar +97 4 412 8733, Bahrain +973 (17) 582 612, KSA +966 (1) 478 0282 quoting thepolicy and membership numbers. Claims must be submitted along with supporting documents within 30 days from date of service. Send this claim form together with supporting material to Medical Department, AXAInsurance, PO BOX 32505, Dubai, UAE or AXA Insurance, P.O. Box 45, Kingdom of Bahrain or AXA Insurance PO BOX 21044, 11475 Riyadh, Kingdom of Saudi Arabia or AXA Insurance, PO Box 15319, Doha, State ofQatar.