ANNEXURE V
F M C NETWORK UAE
P. O. BOX: 50430, DUBAI, Tel – 04 3871900, Fax – 04 3977842
Email – approval@fmchealthcare.ae Helpline Number: 600-565691

Medical Expenses Claim form

Date

Clinic Name
Emirates

Card Holder’s Name:
SEX

Card Holder’s Tel No
Mobile No
Affix copy of front side of Insurance card

Ins. Card
Valid up to

Company Name
Employee No
Nationality

Clinical Details:
Temp
o c
B.P.
MmHg
Pulse.
/ Min
Sign & Symptoms
Date of onset of illness:
Emergency
Work related
new visit
Follow up visit
Diagnosis

Management plan (Services inside the clinic including injections and investigations)
Doctor’s Name and signature with seal:

Diagnostic Procedures referred outside:

I hereby authorize the physician, Hospital or pharmacy to file a claim for medical services on my behalf and I confirm that the abovementioned examination/Investigation/therapy is given to me by the doctor. I hereby authorize any Clinic, Physician, Pharmacy or any other person who has provided medical services to me to furnish any and all information with regard to any medical history, medical condition, or medical services and copies of all medical and Clinic records.

Date
Signature of the Patient

Pharmaceuticals (to be filled by treating doctor only)

CLINIC
PHARMACY
DIAGNOSTIC CENTRE
HOSPITAL OR OTHER