Claim Form 1
Claim Form 1
Claim Form 1
Scheme:
THE EMPLOYEE / DEPENDENT
(If employee membership card available show impression
in box and leave following items blank)
Date: / /
Signature of Claimant ..
ACCOUNTING INFORMATION
TREATMENT INFORMATION
Doctors fee
Date of Injury or
Commencement of Illness: Drugs
Date of consultation: X - Rays
Date first seen (if ongoing treatment): Laboratory
Diagnosis:
Other (Please give details)
Services Rendered:
(e.g. Consultation, tests or investigations etc.)
Total
NOTE TO THE SCHEME MEMBER
Drugs Prescribed: To obtain reimbursement this form must be given to your
employer together with confirmation of payment
General Agents: Al Samiya Corporation - Head Office: P.O. Box: 2302 - Riyadh 11451 - Kingdom of Saudi Arabia - Telephone: (01) 477 9229 - Fax: (01) 478 9219 - e-mail: riyadh@medgulf.com
e-mail: riyadh@medgulf.com - )01( 478 9219 : - )01( 477 9229 : - - 11451 - 2302 :. : - :