Form Frm-Cf - Claim Form printable pdf download

Download our

International Healthcare Plans for Qatar

MyHealth app

Claim Form

Quick and easy claims submission

1. Provide a few key details

2. Take a photo of your receipt(s)

Please complete this form in BLOCK CAPITALS. For your convenience, this form (in PDF

And you’re done

format) is available on our website:

1 Policyholder’s details

Policy Number

First name

Surname

Date of birth

(DD/MM/YY)

Latest correspondence address

Telephone number

(incl. country code and area code)

Do you have any national/public or state provided health insurance cover in your home country or country of residence e.g. National Health Insurance?

Yes

If Yes, please provide a description of the cover provided along with your reference number/identifier with the state.

2 Patient’s details (if different from policyholder)

First name

Surname

Date of birth

Gender:

Male

Female

(DD/MM/YY)

3 Payment details

Payment to policyholder

Option 1:

Preferred payment method:

Bank

transfer*

Cheque**

Please specify the currency you would like to be reimbursed in (and ensure that your bank account supports it)

Name of bank account holder as shown on your bank statement

Account number

IBAN (where

required)***

Sort/branch code

BIC/Swift

code***

Name of bank

Bank address

If you are aware of any additional information required in order to process international transactions within your country (e.g. Agency Code, Tax ID), please list below:

Swift code of intermediary bank (where applicable)

For bank transfer, please provide bank details.

Cheques payable to the policyholder will be sent to the correspondence address provided in section 1.

***

If your bank is within the EU, or if your specific country requires an IBAN (e.g. Qatar, Saudi Arabia, Angola, Tunisia, Turkey), please supply both your IBAN and BIC/Swift code to facilitate the payment of your claim.

Option 2:

Payment to medical provider (e.g. hospital,

specialist)****

Please tick if direct billing has been previously agreed with us

**** If you have not already paid the medical provider.