Follow the steps to complete your claim form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the policy number in the designated field labeled 'Policy No' at the top of the form. Ensure this number is correct to avoid any delays.
3. In the 'Group Name' section, provide the name associated with your insurance group. This information helps in processing your claim accurately.
4. Fill in the patient's name exactly as it appears on the insurance documents in the 'Patient’s name' field.
5. Enter the date of birth in the format of day/month/year in the corresponding field.
6. Input the claim number assigned to your case in the 'Claim No' section to assist with tracking the status.
7. Record the date of the claim submission in the 'Claim date' box, using the same day/month/year format.
8. Provide the authorization number relevant to your claim in the 'Authorization No' field.
9. Enter the staff number in the 'Staff No' section, ensuring it is accurate.
10. Fill in the staff bank account number in the 'Staff Bank A/c No' space if needed for reimbursements.
11. In the 'Agent Name' field, include the name of the agent responsible for the claim process if applicable.
12. Check the boxes for the required documents you are enclosing, such as detailed medical reports and itemized invoices. Ensure any documents not in Arabic, English, or French have been translated.
13. Fill in the claimed amount in the section to be filled by Fidelity, ensuring that it matches the invoices provided.
14. After your submission, note the approved amount and beneficiary share filled by NEXtCARE.
15. In the section where NEXtCARE indicates the approval status, ensure to check off approved, partially declined, or totally declined based on your situation.
16. Finally, ensure the medical auditor has signed and dated the form before submission.
17. Once the form is complete, save any changes made, and you may print, download, or share the form as required.

Begin filling out your Nextcare Claim Form online today for a smoother reimbursement experience.