py Mantra Ayurveda Clinic FZ - LLC TO WHOM SO EVER IT MA’ Ni Patient Name: MR. SUBIN KRISHNANKUTTY BABU Assessment/ Diagnosis: LUMBAGO Chief Complaints: Complaining of severe pain over the lower back region and difficulty to the spinal movements Advised Treatment:09 sessions of Ayurveda Treatment. Total Paid:Aed. 3600/- 07/03/2024 R Ref. No, MAC/INS 4904.C/24 Invoice No:1510 st Date Treatment Details Treatment | NO. Fees 22/02/2024 Consultati 7 00. 01 22/02/2024 Kizhi+Lepanam+Kadivasthi+Swedanam 0.00 (02 [20/02/2024 Kizhi+Lepanam+KadivasthisSwedanam | 400.00 03 | 25/02/2024 KizhitLepanam+KadivasthitSwedanam | _400.00__ 4 it LepanamKadivasthi+Swedanam 400.00 (05 | 01/03/2024 | Kizhi+Lepanam+Kadivasthi+Swedanam 400.00 (06 | 03/03/2024 | Kizhi+Lepanam+Kadivasthi+Swedanam 400.00 07 04/03/2024 | KizhitLepanam+Kadivasthi#Swedanam | 400.00 (08 05/03/2024 | KizhitLepanam+Kadivasthi+Swedanam | 400.00 (09 | 07/03/2024 | Kizhi+Lepanam+Kadivasthi+Swedanam | _ 400.00 TOTAL (AED) [3600.00 Site No. 2001-648 lck Rar Rl Dubs Hel Care Cty (DHCC) Meta Dabs UAE |‘TAX INVOICE Wy ee sae.) wvoiceno: 1510 pate: 22/82/2924 Name: Sulain. kxishnaoludly Bab. en [ew Efer TT Is. o.] Description Gann F_uatrece [Tout Anoun nity Toh [nef _Bhe | Fs ‘Ayurveda Clinic FZ + LLC iahithie paca | adiwaskit — |q_ |400]- BSe) ISWe dances MANTRA Ayurveda Clinic FZ LLC PAID cmon [3boeI w Of |OS ToMPEDISE SY) | patance 0 Box: 19% Ye: 04 440), Fax OLED Era manasa ae ese a tor Da Heat Car City DMCC, Ou Meth Dbsi- UAE Suite No, 2001, AlRasBskng NOB wewayurvedaaeNAS Reimbursement Claim Form RIC It you have any questions regarding this form or any other aspects of your cover, Please telephone NAS (+9712 6940800) or Toll Free 800 2311 Details of member/patient Employes Nome bier Babin rears as peen | Sabin Babu, Gob Abin Company Name TM IeTolcTo Tata ole Ta} | Employee No! Stat ID No: 453 Dao O65" Oy Lage Employee's Tel nuroer Loon Expiojees Ema acckpss Subio babu Tanai fidian Medical section stotens compet paerts nescapacioner attones ste competed Bleck cnt Physician's name ane adcress Br Bigs bag th ads Tard batons pnts mica adore ana" te parc drs giver a et best ct My Noatesge vue ara conte Diagnosis Lum bage ASO. RES SEN SL Other insurer's detals ¢-vresesnnenn in aun ret fn ene fy SEL Patient Section eee ‘Out Patient Treatment Clamed Amount | In Patient Treatment | Claimed Amount Consuitation Hospital charges! Room Pharmacy ‘Surgeny/AnesthesiaiOT Drugs/Labs/Others jnost Others 3600 BES igs/Li fountry of Treatment Une. Teial Claimed Amount and Claimed Currency 4600 hee Patient's declaration and consent SRE sown Ly Toecog eciores recremenan nee owen ‘nove anes cae aut erat oes 9 once are bee Q1'/ 03/2024 cao WAS apie ra py os cone sa ave he aka BRE OF