Follow the steps to successfully complete your reimbursement claim form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient’s name exactly as shown on the insurance card in the first field. This is crucial for identification purposes.
3. Input the patient’s Health Card No. or Emirates ID No. in the designated area to authenticate the claim.
4. If applicable, provide the group member’s name in the appropriate field to link the claim to the correct group.
5. In the section regarding the reason for not using listed healthcare facilities, select the appropriate option such as emergency, elective, or specify any other reason.
6. Medical information should be filled in by the treating doctor. Ensure the doctor provides details such as the condition requiring treatment, visit date, onset and duration of illness, and treatment specifics.
7. Include the name and address of the hospital or clinic where treatment was received, along with the bill number, treatment date, description of services, and amount charged.
8. In the other information section, answer whether the case is work-related and if the claim is covered by another insurance, providing any necessary details.
9. Complete the declaration section by stating your name, signature, date, contact number, and relationship to the cardholder, confirming your understanding of the claim process.
10. Once all fields are completed accurately, review the form for any errors. Then, you may save changes, download, print, or share the completed form as necessary.

Get started on your medical reimbursement claim by filling out the AE ADNIC ADNIC-CONC-01-F02 online today.