AUTHORISATION Pre Invoice: 25934355

Auth. Effective Date 12/06/2021 | Auth. Expiry Date 12/07/2021 | Authorisation. No. 4265062/2846625

Policy Holder Name & Number M/S ARAB POTASH COMPANY. Provider Code & Name E1928 - Dr. MARIA MAKRM GALEB
348145 271534 QOUSSOUS
Insurance Company ARAB POTASH COMPANY Provider Fax Number
Policy Expiry date 01/09/2021 Authorization Type DENTAL
Package 10000 Potash Package Room Type 1 - ‫ﺃﻭﻟﻰ‬
Member Name ‫ﻣﺎﺭﻳﺎﻥ ﻓﺮﺍﺱ ﻋﺎﻃﻒ ﺍﻟﻤﺼﺎﺭﻭﻩ‬ Request date & time 12/06/2021 21:55
Card Number 1126676 Reply date & time 12/06/2021 21:57
Gender & Age FEMALE 4 Issue Date 12/06/2021
File Number Date of admission
National ID 2003557763 Referral Provider -

Diagnosis Code Diagnosis Description Diagnosis Qualifier

ICD9 521 DISEASES OF HARD TISSUES OF TEETH PRIMARY

Tooth Requested Approved Quantity Requested Contractual Member Approved

Services Number Quantity Quantity Type Amount Amount Part Amount
ANTERIOR OR POSTERIOR COMPOSITE FDIC74 1 1 UNIT 15.000 15.000 0.000 15.000
RESTORATION (FILLING) 3 SURFACES

ANTERIOR OR POSTERIOR COMPOSITE FDIC84 1 1 UNIT 15.000 15.000 0.000 15.000

RESTORATION (FILLING) 3 SURFACES

Totals: 2 30.000 30.000 0.000 30.000

Case Number: 1625736 Incident Number: 4265062 Authorization Number: 2846625

Thanking you for your kind co-operation.

Member Name: ‫ﻣﺎﺭﻳﺎﻥ ﻓﺮﺍﺱ ﻋﺎﻃﻒ ﺍﻟﻤﺼﺎﺭﻭﻩ‬ MedNet Claims Center Authorized Signature.

Signature: ........................ MedNeXt OnLine

‫ﻳﺮﺟﻰ ﺻﺮﻑ ﺍﻟﻜﻤﻴﺔ ﺣﺴﺐ ﻭﺻﻔﺔ ﺍﻟﻄﺒﻴﺐ ﺑﺤﻴﺚ ﻻ ﺗﺘﻌﺪﻯ ﺍﻟﻜﻤﻴﺔ ﺍﻟﻤﺼﺮﻭﻓﺔ ﺍﺣﺘﻴﺎﺝ ﺍﻟﻤﺮﻳﺾ ﻟﻤﺪﺓ ﺷﻬﺮ‬

*Strictly Confidential - Contains Medical Information. Not To Be Duplicated or Handled By Unauthorized Personnel