Get Reimbursement Bclaim Formb - Al Sagr Bnationalb Insurance - Alsagrins

This guide provides detailed instructions for users filling out the REIMBURSEMENT CLAIM FORM for Al Sagr National Insurance. It is designed to assist you in completing the form accurately to ensure a smooth reimbursement process.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to acquire the form and open it for editing.
2. Fill out the patient and facility information section. This includes the healthcare facility name, the patient's name, date of healthcare visit, telephone number, date of birth, sex, employer, and card number.
3. Provide details regarding the history of present illness and past medical history. The physician must complete this section, including the reason for consultation, history of present illness, past medical or surgical history, and any current medications.
4. Complete the review of systems and diagnosis section. The physician should document clinical findings, vital signs, and the relevant diagnosis code while specifying if the diagnosis is related to another assessment.
5. List all applicable costs associated with the healthcare services provided. Ensure you include costs for physiotherapy, consultation, pharmacy, laboratory, radiology, and any other services together with the total charges.
6. Indicate if there was a hospital admission, including the hospital name and number of days. Provide the procedure performed and related costs.
7. Attach all necessary itemized original invoices, prescriptions, reports, and receipts to support your claim submission.
8. The treating physician must sign and stamp the form, confirming the accuracy of the provided information.
9. Submit the completed form within 90 days from the date of service, ensuring that you keep a copy for your records.

Complete and submit your reimbursement claim form online today to facilitate your insurance claim process.