Outpatient Claims Details

Outpatient Claim ID : 2606824 Beneficiary ID : 416982

Client Name : ‫ﻣﻮﻇﻔﻰ ﻭﺍﺳﺮ ﺟﻤﻌﻴﺔ ﺍﻟﺨﺪﻣﺎﺕ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ ﻟﻠﺒﻨﻚ ﺍﻻﻫﻠﻰ ﺍﻟﻤﺼﺮﻯ‬ :‫ﺍﺳﻢ ﺍﻟﻌﻤﻴﻞ‬

Beneficiary Name: ‫ﻋﻠﻴﺎﺀ ﻋﻼﺀﺍﻟﺪﻳﻦ ﻣﺼﻄﻔﻰ ﺍﻟﻤﻐﺎﺯﻯ‬ ‫ﻋﻠﻴﺎﺀ ﻋﻼﺀﺍﻟﺪﻳﻦ ﻣﺼﻄﻔﻰ ﺍﻟﻤﻐﺎﺯﻯ‬ : ‫ﺍﺳﻢ ﺍﻟﻤﺆﻣﻦ‬

Card Number : 416982 : ‫ﺭﻗﻢ ﺍﻟﻜﺎﺭﺕ‬

Employee code : NBE/SSA-13640-S
: ‫ﺭﻗﻢ ﺍﻟﻤﻮﻇﻒ‬
Service Name : Lab-Srv : ‫ﻧﻮﻉ ﺍﻟﺨﺪﻣﺔ‬
N39.0 : ‫ﻛﻮﺩ‬
ICD Code :
Provider Branch : : ‫ﺍﻟﻔﺮﻉ‬
Region : : ‫ﺍﻟﻤﻨﻄﻘﺔ‬
Branch Address : : ‫ﻋﻨﻮﺍﻥ ﺍﻟﻔﺮﻉ‬
Notes : : ‫ﻣﻼﺣﻈﺎﺕ‬
Claim form serial : Lab - H1657136 : ‫ﻻ ﻳﺘﻢ ﺗﻘﺪﻳﻢ ﺍﻟﺨﺪﻣﻪ ﺍﻻ ﺑﺎﺭﻓﺎﻕ ﻧﻤﻮﺫﺝ ﺭﻗﻢ‬ : ‫ﺭﻗﻢ ﺍﻟﻨﻤﻮﺫﺝ‬

Medical Diagnoses Medical Proc. / Drug Dose Qty Approval Status Notes
‫ﺍﻟﺘﺸﺨﻴﺺ ﺍﻟﻄﺒﻰ‬ ‫ ﺍﻟﻌﻼﺝ‬/ ‫ﺍﻻﺟﺮﺍﺀ ﺍﻟﻄﺒﻰ‬ ‫ﺍﻟﺠﺮﻋﻪ‬ ‫ﺍﻟﻜﻤﻴﺔ‬ ‫ﺣﺎﻟﺔ ﺍﻟﻤﻮﺍﻓﻘﺔ‬ ‫ﻣﻼﺣﻈﺎﺕ‬
Helicobacter pylori antigen (in stool) 1 Approved
Urine Culture&Sensetivity 1 Approved

Unspecified Lab
20%
28/07/2021
2606824
Abdelhakim Nofal
7 :

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