Medical Claim Form Template for United Arab Emirates

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Key Requirements PROMPT example:

Medical Claim Form

I need a Medical Claim Form for my Dubai-based tech company's group health insurance policy that will cover both outpatient and inpatient claims, including international treatment coverage, to be implemented by March 2025.

Document background

The Medical Claim Form is a essential document in the UAE healthcare system, designed to facilitate the reimbursement process for medical expenses under the mandatory health insurance scheme. It is used when patients seek reimbursement for medical services, treatments, or medications covered under their insurance policy. The form must comply with UAE Federal Law No. 2 of 2019 regarding health data protection, as well as specific requirements set by the Dubai Health Authority and Department of Health Abu Dhabi. This document is particularly crucial in cases where patients have paid for medical services directly and are seeking reimbursement, or when healthcare providers are submitting claims on behalf of patients. The form includes comprehensive sections for patient details, treatment information, cost breakdown, and necessary declarations, ensuring efficient processing while preventing fraudulent claims.

Suggested Sections

1. Claimant Information: Personal details of the patient including Emirates ID, insurance policy number, and contact information

2. Policy Details: Insurance policy information including policy number, insurance provider, and coverage period

3. Medical Service Details: Information about the medical service received, including dates, healthcare provider details, and type of service

4. Claim Details: Specific details about the medical expenses being claimed, including itemized costs and total claim amount

5. Payment Information: Preferred method of reimbursement and banking details for claim settlement

6. Declaration and Consent: Legal declarations, privacy consent, and authorization for accessing medical information

7. Healthcare Provider Certification: Section for healthcare provider to certify the services rendered and costs charged

Optional Sections

1. Third Party Insurance Details: Required when claim involves another insurance provider or liability party (e.g., workplace injury or road accident)

2. Pre-authorization Information: Required for treatments that needed pre-approval from insurance provider

3. Chronic Condition Details: Additional section for claims related to ongoing chronic conditions

4. International Treatment Details: Required for medical services received outside the UAE

5. Employer Certification: Required for company-sponsored insurance claims

Suggested Schedules

1. Medical Bills and Receipts: Checklist and attachment section for all relevant medical bills and payment receipts

2. Medical Reports: Checklist and attachment section for supporting medical documentation

3. Prescription Documents: Attachment section for prescription details and pharmacy bills

4. Pre-authorization Documentation: Attachment section for pre-approval documents where applicable

5. Coverage Terms Summary: Summary of relevant insurance coverage terms and conditions for the claimed treatment

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Insurance

Medical Services

Pharmaceutical

Employee Benefits

Healthcare Administration

Risk Management

Compliance

Legal Services

Relevant Teams

Claims Processing

Member Services

Provider Relations

Compliance and Risk

Healthcare Administration

Patient Accounts

Benefits Administration

Medical Records

Finance and Billing

Customer Service

Quality Assurance

Operations

Relevant Roles

Insurance Claims Processor

Medical Claims Specialist

Healthcare Administrator

Insurance Coordinator

Medical Records Officer

Compliance Officer

Benefits Administrator

Insurance Underwriter

Healthcare Finance Manager

Patient Services Representative

Medical Insurance Specialist

Claims Auditor

Healthcare Operations Manager

Risk Assessment Officer

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Let's create your Medical Claim Form

Authors

Alex Denne

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