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Reimbursement Instructions by s42gs6

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									                            Reimbursement Instructions
Very Important Notes:
   1.   Filling all fields of the Reimbursement ASOAP Form is mandatory
   2.   Diagnosis must be mentioned in the ASOAP Form
   3.   Charges of services must be mentioned in the ASOAP Form
   4.   Reimbursement ASOAP Form must be duly signed & stamped by the treating physician

REQUIRED DOCUMENTS
   1st.       Outpatient Services
   A. Consultation
         a. Reimbursement ASOAP Form signed & stamped by the treating physician
         b. Copy of the membership card
         c. Consultation fee invoice (original)
   B. Medications
         a. Reimbursement ASOAP Form signed & stamped by the treating physician
             including the prescribed drugs.
         b. Copy of the membership card
         c. Pharmacy invoice (Original)
   C. Radiology & Laboratory
         a. Reimbursement ASOAP Form signed & stamped by the treating physician
         b. Copy of the membership card
         c. Results of the Laboratory & Radiology investigations (Original)
         d. Laboratory Or Radiology center invoice (Original)
   D. Physiotherapy Sessions
         a. Reimbursement ASOAP Form signed & stamped by the treating physician
         b. Copy of the membership card
         c. Medical Report detailing number &type of sessions performed. (signed
             &Stamped by the physiotherapist)
         d. Physiotherapist fee invoice (Original)
   E. Dental Services
         a. Reimbursement ASOAP Form signed & stamped by the dentist
         b. Copy of the membership card
         c. Detailed invoice of the dentist fees (Original)
         d. Medical report detailing the description of service (Filling- Extraction…), the
             type of service (Amalgam or Composite Filling- Simple or Surgical Extraction)
             ,Number& Surface of tooth (signed &Stamped by the dentist)
   F. Optical Services Claim
         a. Reimbursement ASOAP Form signed& stamped by the opthalmologist
         b. Copy of the Membership card
         c. Eye sight test report
         d. Ophthalmologist / Optometrist fee invoice (Original)
         e. Spectacles invoice (Original)
G. Maternity
     a. Reimbursement ASOAP Form signed& stamped by the obstetrician
     b. Copy of the Membership card

       1. Follow up
             i. Consultation (as mentioned earlier)
            ii. Investigations (as mentioned earlier)
           iii. Medications (as mentioned earlier)
       2. Delivery
             i. Reimbursement ASOAP Form signed& stamped by the obstetrician
            ii. Copy of the membership card
           iii. Detailed medical report (Original) signed &stamped by the obstetrician.
           iv. Hospital charges detailed invoice (Original)
            v. Obstetrician fees invoice(Original)
           vi. Copy of the newborn birth certificate
2nd.      Inpatient Services
       a.   Reimbursement ASOAP Form signed& stamped by the treating physician
       b.   Copy of the Membership card
       c.   Detailed Medical report (Signed & stamped by the obstetrician
       d.   Hospital charges detailed invoice (Original)
       e.   Surgeon fee invoice (Original)
‫ى‬          ‫داد ا‬                ‫تا‬                                    ‫ت‬
                                                                                                                                                                         ‫ته‬
                      ‫داد ‪Reimbursement ASOAP form‬‬                                             ‫ذج ا‬         ‫دة‬      ‫تا‬                        ‫ا‬                                 ‫1.‬
                                                                                                 ‫داد‬         ‫ذج ا‬                                     ‫ا‬         ‫آ‬               ‫2.‬
                                                          ‫.‬                    ‫ا‬           ‫ا‬             ‫داد‬      ‫ذج ا‬                            ‫و‬                             ‫3.‬
         ‫آ ت(‬   ‫.)‬         ‫تآ‬                ‫ا‬            ‫ا‬                   ‫وا‬               ‫ءا‬       ‫ا‬                                     ‫ا‬                                 ‫4.‬
                                                                                                                                                                         ‫ات ا‬        ‫ا‬
                                                                                                                               ‫ر‬          ‫دات ا‬                 ‫تا‬          ‫أو :‬
                                                                                                                                                               ‫1. ا‬
                                                              ‫ا‬                       ‫ا‬                         ‫مو‬                 ‫داد‬                    ‫ذج ا‬              ‫1. ا‬
                                                                                                                                     ‫.‬                    ‫رة ا‬              ‫2. ا‬
                                                                                                                                         ‫ا‬                           ‫رة‬       ‫3.‬
                                                                                                                                                   ‫2. ا دو‬
                                                                              ‫ا‬           ‫ا‬                               ‫مو‬                      ‫داد‬               ‫ذج ا‬      ‫1.‬
                                                                                                                                          ‫ا‬                           ‫رة‬      ‫2.‬
                                                                                                            ‫.‬         ‫ا‬                  ‫ا‬            ‫رو‬              ‫رة‬      ‫3.‬
                                                                                                                               ‫.‬                      ‫رة ا‬                  ‫4. أ‬
                                                                                                                                    ‫ت وا‬                       ‫3. ا‬
                                                                              ‫ا‬           ‫ا‬                               ‫مو‬                      ‫داد‬               ‫ذج ا‬      ‫1.‬
                                                                                                                                         ‫ا‬                            ‫رة‬      ‫2.‬
                                                                                                            ‫ت.‬            ‫وا‬                      ‫ا‬                         ‫3. أ‬
                                                                  ‫.‬                ‫آ ا‬         ‫او‬           ‫ا‬                      ‫درة‬                ‫ا‬        ‫ا ا‬          ‫1. أ‬
                                                                                                                                              ‫جا‬               ‫4. ا‬
                                                                              ‫ا‬           ‫ا‬                               ‫مو‬                      ‫داد‬               ‫ذج ا‬      ‫1.‬
                                                                                                                                         ‫ا‬                            ‫رة‬      ‫2.‬
                            ‫.‬          ‫جا‬        ‫آ ا‬                               ‫مو‬   ‫ت‬   ‫دو ع ا‬                                                                            ‫3.‬
                                                                      ‫.‬              ‫آ ا جا‬        ‫و‬                                                      ‫رة‬         ‫ا‬      ‫4. أ‬
                                                                                                                           ‫ن‬                  ‫تا‬                    ‫5.‬
                                                              ‫ن‬                   ‫ا‬                                       ‫مو‬                      ‫داد‬               ‫ذج ا‬      ‫1.‬
                                                                                                                                         ‫ا‬                            ‫رة‬      ‫2.‬
                                                          ‫ن‬               ‫ا‬                             ‫و‬             ‫ج‬             ‫ا‬                      ‫رة‬               ‫3. أ‬
    ‫اء‬     ‫ا‬         ‫ا ى‬        ‫س وا‬        ‫ور ا‬              ‫وو‬                          ‫اءه‬       ‫ا‬           ‫تا‬             ‫ا‬                                              ‫4.‬
                                                                                                                ‫ن.‬         ‫ا‬                                     ‫مو‬
                                                                                                                ‫دة‬        ‫وا‬              ‫ا‬                         ‫6.‬
                                                     ‫دة‬   ‫ء وا‬                    ‫ا‬                                       ‫مو‬                      ‫داد‬               ‫ذج ا‬        ‫1.‬
                                                                                                                                         ‫ا‬                            ‫رة‬        ‫2.‬
                                ‫ط أ،ب،ت(‬         ‫ا‬                             ‫ذآ‬          ‫)آ‬           ‫ا‬            ‫أ(‬
                                                                                                                                                                            ‫1. ا‬
                                                                                                                                                            ‫ت‬               ‫2. ا‬
                                                                                                                                                                         ‫3. ا دو‬
                              ‫دة‬       ‫ا‬            ‫ب(‬
                       ‫ء وا‬    ‫ا‬                ‫م‬        ‫و‬                                    ‫1.‬
    ‫ء وا‬   ‫ا‬                       ‫و‬                                     ‫ا رة ا‬             ‫2. أ‬
                                                                 ‫.‬      ‫تا‬    ‫أ‬             ‫3. أ‬
                                                         ‫.‬           ‫رة دة د ا‬                ‫4.‬
                                                     ‫.‬               ‫رة ا ب ا‬               ‫5. ا‬

‫(‬          ‫ا‬           ‫ت ا‬    ‫تو‬           ‫)آ‬                ‫ا‬                 ‫ا‬        ‫ت‬      ‫:‬
                   ‫ا‬          ‫ا‬                          ‫مو‬              ‫داد‬       ‫ذج ا‬       ‫1.‬
                                                                     ‫ا‬               ‫رة‬       ‫2.‬
                                                                     ‫.‬                        ‫1.‬
               ‫.‬              ‫ا‬                 ‫و‬                         ‫رة ا‬      ‫ا‬       ‫2. أ‬
                                                                 ‫.‬       ‫تا‬         ‫أ‬       ‫3. أ‬
 Reimbursements Statement
 Policy Holder: ________________________


 Number of Claims:


                                           Number of    Total
Serial   Beneficiary Name     Card No.
                                           Documents    Amount




Total Amount




                                           Signature:

                                           Stamp:

								
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