Dental Services Authorization Letter

‫ﺧﻄﺎﺏ ﻣﻮﺍﻓﻘﺔ ﺧﺪﻣﺎﺕ ﺍﻷﺳﻨﺎﻥ‬

Dear/ C943 Dr. Mai Mamdouh Ahmed, ،‫ ﻣﻲ ﻣﻤﺪﻭﺡ ﺍﺣﻤﺪ‬/‫ ﺩ‬/ ‫ﺍﻟﺴﺎﺩﺓ‬
Kindly assist MedNet card holder to get your best services, with our ‫ﺑﺮﺟﺎﺀ ﺗﻘﺪﻳﻢ ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﻜﺎﻣﻠﺔ ﻟﺤﺎﻣﻞ ﺑﻄﺎﻗﺔ ﻣﻴﺪﻧﺖ ﻭﻣﺴﺎﻋﺪﺗﻪ ﻓﻰ ﺍﻟﺤﺼﻮﻝ ﻋﻠﻰ ﺃﻓﻀﻞ‬
sincere wishes for a quick recovery and good health. .‫ ﻣﻊ ﺧﺎﻟﺺ ﺗﻤﻨﻴﺎﺗﻨﺎ ﻟﻪ ﺑﺪﻭﺍﻡ ﺍﻟﺼﺤﺔ ﻭﺍﻟﻌﺎﻓﻴﺔ‬،‫ﺧﺪﻣﺎﺗﻜﻢ‬
Thank you for your kind cooperation ‫ﻭﺷﻜﺮﺍ ﻟﺤﺴﻦ ﺗﻌﺎﻭﻧﻜﻢ‬

Total Authorization
‫ﻣﻮﺍﻓﻘﺔ ﻛﺎﻣﻠﺔ‬
Expiry Date: 26/01/2023
Authorization Date: 16/01/2023 Authorization No.: 6412326
‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻮﺍﻓﻘﺔ‬
‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻮﺍﻓﻘﺔ‬ ‫ﺭﻗﻢ ﺍﻟﻤﻮﺍﻓﻘﺔ‬
Beneficiary Name: ‫ﺍﺳﻢ ﺍﻟﻤﺴﺘﻔﻴﺪ‬ Card Number: 650276
Orient Takaful Insurance Company - MRe
Mohamed Gomaa ‫ﺭﻗﻢ ﺍﻟﺒﻄﺎﻗﺔ ﺍﻟﻄﺒﻴﺔ‬
Diagnosis: Diagnosis Code: 521.0
DENTAL CARIES
‫ﺍﻟﺘﺸﺨﻴﺺ‬ ‫ﻛﻮﺩ ﺍﻟﺘﺸﺨﻴﺺ‬

Authorized Services: :‫ﺍﻟﺨﺪﻣﺎﺕ ﺍﻟﺘﻰ ﺗﻤﺖ ﺍﻟﻤﻮﺍﻓﻘﺔ ﻋﻠﻴﻬﺎ‬

The below services will be paid as per contracted rates ‫ﺳﻮﻑ ﻳﺘﻢ ﺍﻟﻤﺤﺎﺳﺒﺔ ﻋﻠﻰ ﺍﻟﺨﺪﻣﺎﺕ ﺍﻟﺘﺎﻟﻴﺔ ﻭﻓﻘﺎ ﻷﺳﻌﺎﺭ ﺍﻟﺘﻌﺎﻗﺪ‬

Service Name Tooth Number Approved Quantity CO-Payment

Amount
‫ﺍﺳﻢ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺴﻦ‬ ‫ﺍﻟﻤﻮﺍﻓﻖ ﻋﻠﻴﻪ‬ ‫ﻣﺒﻠﻎ ﺍﻟﺘﺤﻤﻞ‬
‫ﺣﺸﻮ ﻛﻮﻣﺒﻮﺯﻳﺖ‬ N/A 3.000 36.00
‫ﺣﺸﻮ ﺍﻟﺠﺬﻭﺭ ﻟﻠﻀﺮﻭﺱ ﺍﻷﻣﺎﻣﻴﺔ ﻭﺍﻟﺨﻠﻔﻴﺔ‬ N/A 3.000 72.00
‫)ﺇﺯﺍﻟﺔ ﺍﻟﺮﻭﺍﺳﺐ ﺍﻟﺠﻴﺮﻳﺔ ﺑﺎﻟﻔﻜﻴﻦ )ﻛﺎﻓﻴﺘﺮﻭﻥ‬ N/A 1.000 12.00
Totals 7.000 120.00

Notes: :‫ﻣﻼﺣﻈﺎﺕ‬
LR5
LL5,6

Authorizing Doctor Code: Stamp & signature

Provider User Name:
Invoice Number: 23408020
Department:
Originally Created In: 16/01/2023

Hotline Number: 202 24636100 Fax Number: +202 24636101 Page No(s): 1/1
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