Direct Billing Claim Form
This claim form is not an admission of liability.
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.
I declare that I am the patient's medical practitioner, and that the particulars given areto the best of my knowledge true and correct.