Self Assessment
Nextcare Reimbursement Claim Form
ADMINISTRATIVE
HealthcareProvider:
Patient’sName:
Patient’sFileNo.#:
Date of Service:
DOB:
Patient’s Tel:
Sex:
Emirates ID No:
Email address:
Insurance Company:
NextCare Insurance Company
Account Name:
UAE IBAN Number:
UAE Bank Name:
UAE Swift Code:
SUBJECTIVE (To be completed by Physician)
Symptom(s) As Described by Patient (CHIEF COMPLAINT)
What date did the Patient first feel same / similar symptom(s):
Is the Patient under any type of treatment/Meds:
Yes
No
If yes, indicate what assessment and since when:
OBJECTIVE / ASSESSMENT (To be completed by Physician)
Vital Signs:
BP:
Temp:
HR:
RR:
Past Medical & Surgical History:
Clinical Details & Description of Present Case:
Cause:
Physical Illness
Accident
Maternity
Preventive
Psychiatric
Dental
Work Related
Acute
Chronic
Confirmed
Suspected
Other
Assessment / Diagnosis: INDICATE DIAGNOSIS NOT SYMPTOM
Diagnosis :
ICD Code:
Is Assessment / Diagnosis related to another Assessment?
Yes
No
If yes, specify: (i.e. Retinopathyrelated to Diabetes):
MEDICAL PLAN
Itemized Original Invoices and Applicable Prescriptions / Reports / Results must be enclosed to consider claim
TOTAL CHARGES
Was In-patient Required? Length of Stay
Indicate Provider Cost
Discharge Summary: Itemized Invoices, Reports & Receipts
Treating Physician Name:
Name & Address of Facility:
Tel/ Fax:
Email:
I hereby authorize any Healthcare Provider, Insurer, Employer or other Organization to release any information regarding mymedical condition & history to NEXTCARE for the purpose of determining insurance benefits.
Signature & Stamp:
Patient's Signature (parent if minor)
Date:
Patient Signature
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