Self Assessment
Sukoon Insurance Claim
Medical Authorization Centre: 800 6626
General Inquiries: 800 SUKOON (785666)
DIRECT BILLING - HEALTHCARE INSURANCE
OUTPATIENT CLAIM FORM
One Claim Form per person
Section 3 & 4 to be filled by treating doctor & Section 5 by patient. All other sections to be filled by Administrative Personnel. Please write in BLOCK LETTERS. In case additional details need to be provided, please photocopy this sheet.
1.Provider Details
1. Provider Name
//
2. Facility License Code
//
2. Member/Patient Details
Card Number
Date of Birth(dd/mm/yyy)
Patient’s Name (as it appears on the card)
Telephone Number
Gender
Medical Record Number
Reason for Visit
Emergency
Road traffic accident
Work related accident
New visit
Follow up
Referral
Referral source
3. Medical Section
Chief complaint & duration
First consultation date for above condition (dd/mm/yyyy
Initial Diagnosis
Please tick theappropriatebox
Maternity
Acute
Chronic
Congenital
If maternity related, please indicate LMP
How long patient is aware of the complaint?
Final Diagnosis
ICD Code(s)
TreatmentDetails
CPT Code(s)
Pre authorisation
4. Doctor’s Declaration
I declare that I am the patient’s treating doctor and the particulars given are trueand correct to the best of my knowledge
Doctor’s Stamp
Signature
Date
5.Patient’sDeclaration
I confirm that all particulars above are true. I hereby authorize (i) the medical provider and any other entity to provide and discuss health/treatment details with Oman Insurance Companyand/or thirdparty administrator(ii)Oman InsuranceCompany to (a)disclose my personal/claim information for claimprocessing or as may be required(b)contact me for claim/other products information.I agree that a copy of this consent shall have the validity of original.
Name
Signature
Date
Print
Patient Signature
X
