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Neuron Direct Billing Claim Form - Dental Section A - Details of Member/Patient Neuron ID Number Patient s Name Date of Birth Mobile Number Gender M Provider Code Name Fax number Location F Tel number Diagnosis Presenting complaint s History of Present Illness/ duration of the condition Clinical findings Tooth as per the chart below Surface Dental Procedure Procedure Code s Cost as per agreed tariffs Consultation X-Ray Amalgam/composite/ temporary filling RCT Extraction Scaling/prophylaxis Others Pls specify Total cost Permanent Teeth Upper right Deciduous Teeth Upper left Lower right Lower left Medication prescribed Diagnosis should be mentioned same as that on the doctor s prescription Any Additional relevant information that is Material fact to this case Section C - Treating Physician/Doctor s declaration I declare that I am the patient s treating Physician and that the particulars given are to the best of my knowledge true correct and in line with my/our Agreement with Neuron. Signature Date / Medical Practitioner s Stamp Section D - Patient s declaration patient to affix signature in this section along with date I confirm that I am the patient or the patient s parent or guardian if the patient is under 16 years of age and declare that all the particulars given above are true. I hereby consent to and authorise the medical provider health professional or other relevant medical establishment to provide and discuss any health/treatment details medical records or discharge arrangements past and present with and to the Insurer and /or Third Party Administrator. I agree that a copy of this consent shall have the validity of the original* Section D - Other insurer s details if the treatment is accident-related or covered under another insurance policy please provide details Insurance Company Name Policy Number Helpline Toll-free Tel No UAE 800 4408 / 800 4 36292 ENAYA INTERNATIONAL Helpline 97143823600 OMAN 800 72211 Completed claim form along with supporting documents should be submitted to Neuron within the stipulated time-frame for submissions to be considered for payment as per relevant terms and conditions. I hereby consent to and authorise the medical provider health professional or other relevant medical establishment to provide and discuss any health/treatment details medical records or discharge arrangements past and present with and to the Insurer and /or Third Party Administrator. I agree that a copy of this consent shall have the validity of the original* Section D - Other insurer s details if the treatment is accident-related or covered under another insurance policy please provide details Insurance Company Name Policy Number Helpline Toll-free Tel No UAE 800 4408 / 800 4 36292 ENAYA INTERNATIONAL Helpline 97143823600 OMAN 800 72211 Completed claim form along with supporting documents should be submitted to Neuron within the stipulated time-frame for submissions to be considered for payment as per relevant terms and conditions.

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