Daman Reimbursement Claim Form

2. Claims Payment Details

Wire Transfer (Please provide the bank account details to which Daman should transfer the money for this reimbursement claim.)

Beneficiary Name

Bank Name:

Branch, Bank Address:

Account Number:

Swift Code Number: (For International Transfers)

IBAN Number:

I authorise the National Health Insurance Company – Daman PJSC (“Daman”) to make a wire transfer payment against this Reimbursement Claim Form and hereby discharge Daman from any liability with respect of releasing the payment to the bank details as specified by me hereinabove.

3. Medical Information

Visit Date:

Reason for visit/Chief Complaints:

Diagnosis :

ICD Code:

Treatment Details:

Currency (If treatment is availed outside UAE):

Total Amount Paid:

4. Checklist – please check that you have included all of the following as required: (Failure to provide the required below documents may result in rejection or delay in the processing of your claim).

Invoices/bills with a breakdown of each medical service and its unit cost. It must show a confirmation of payment or a corresponding receipt.

Complete Medical Report/ discharge summary or a precise identification of the illness (diagnosis) or description of the symptoms by the doctor

Prescription(s) for medications and medical appliances

5. Terms & Conditions/Authorisation

I agree to the Terms and Conditions herein (refer to the terms and conditions in page 2)

I hereby authorise Mr. /Ms. /Company to receive medical information related to this claim from Daman on my behalf.

Name of Daman member/ Legal Guardian/ Legal Representative

Date :