CHRONIC CLAIM FORM im oS KFH takafal GlobeMed Kuwatt Insweds Name _— Employee # ontact Number Insurance Co Mobie # {naivigual Number Date of visit coe Policy Holder (To be compited by the Atending Py ian) Doctors Name Mobile # Specialty DURATION OF DISEASE CHEE COMPLAINTS ‘TREATMENT PLAN Medicine Name leSubstiute [Dose | Frequency | Duration |gheundersened erebydecle ie folowing: give fll athozatan tothe Insurance Company and/or employer adhering to GlobePied and I's reprasentatives to Inquire about my past and actual siete of heath | also autheize them o Inform ny, attending physician within their apace, ofthe Information avalape et thelr 2 about my state of health Henea, request from the healthcare provide! to eves! and Drove th insurance Company and/or employer anc GlobeHed anit feprasentatves, ‘thal pvaliable information conce:ning my person that are known to them or that are Feld in thelr files and medical recorcs ana photocopies oft name SIGNATURE reby certify that ALLinformation mentioned ave cortect & thatthe medial services shown fn this form were medially indiated & Mecessary for the management of ts case, or. Physician SIGNATURE & STAMP