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MedNet
Reimbursement Form
Card Holder's Name:
Card No
Valid Uni zune Contact Telephone:
To be completed by the treating Physician
‘Dear Doctor: The beneficiary parlpaing nthe MedNet Pragram is consuing you Tor medoal cova and Kindly requests you To compe
fou
Diagnosis
Dato of onset of symptoms
Date of
hospitalized ‘Admission
Discharge
Case Management
Actual Costs Pore eee
Treatment Plan
Diagnostic Tests,
Date
Physician's Name
Telephone No
Physician's Stamp and Signature
bate
MogNet UAE FZLLC.
P.O Box 500258 Dubs
Internet Gay, Oubal ~ UAE
Yel: +97143800710 Fax! »6714 3908600 Ema inlog@mednotuae com Web: wa mednetuae com
eietly Confdential~ Contains Medical information, Not To Be Duplicated or Handled By Unauthorized PersonnelCHECKLIST
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Completad "Reimbursement Form”
Full and Complete Medical Report / Diagnosis / Discharge summary from the treating doctor FOR
INPATIENT CLAIMS ONLY
Original itemized invoices or receipts for the amount claimed (Invoice must show cost per service)
Copies of results of diggnostic tests
For treatment within UAE, please submit your ciaim within 60 days from the date of treatment For treatment
outside UAE, the claim must be submitted within 80 days from the date of treatment
ModNot UAE FZ LLC.
0 Box s00260 Dub srt Gy, Dubal~ UAE
olss071 «se00r19 Fax 1871 43908600 E-malInbairestctuae com Webs naw mednet uae com
sttcuy Contidentit~ Contains ical Information. Net To Be Duplicated or Handled By Unauthorized Personnel