Authorized Claim Form No : BP0000162684/1 *BP0000162684/1*

NEXtCARE TPA On Behalf Of the Payer : Misr Insurance

Provider Name Al Eman Scan Center. Domiett - HO User Name

This claim form is valid
Date 26-Feb-2024 04-Mar-2024
until

Patient Information
Patient Name Hamdy Rabea aboelfath Elbostany Date Of Birth 16-Nov-1997
Policy No. 3491 Expiry Date 01-Jul-2024
Policy Holder KONDA Card No E0A6-1A45-A28D-559E
Product conda cosmetics Class
Priority Payer
Patient File No Pin # Kon-88234991
Medical Information
Physician Name Family Of Benefits Out-Patient
Physician Specialty Prescription Motive Physical Illness
Consultation Date 26-Feb-2024 Service Date 26-Feb-2024
ER Triage 0 Approved L.O.S. 0 Days
Emergency No ICD Code M25.569 Pain in unspecified knee

Chief Complaints and Main Symptoms

Remark
w-ray on both knee

attach blue form

The approval is according to the agreed Tariff of the medical provider with NEXtCARE.

Disclaimer
In the event of any modifications to the approval, the approvals’ department must be informed as soon as possible to amend the attached approval. If the approvals’ department is not notified, part or all of
1.
the attached claim may be deducted.
2. The approval is issued according to the data sent by the service provider. In the event of any deficiency or error in the transmitted data, the company has the right to withdraw or cancel the sent approval.

3. The Last updated copy of the approval sent must be submitted with the claim.
The company pays the claims in compliance with the approval issued, and issues the final invoice after the financial and medical review and in accordance with all internal regulations and customary in
4.
the review.
5. If you have any questions, please contact customer service + 20 2 24632300 available around the clock, hotline19154, or email cs.eg@nextcarehealth.com

Provider Name & Signature Patient Name & Signature

Al Eman Scan Center. Domiett - HO Hamdy Rabea aboelfath Elbostany

NEXtCARE
Plot 14B01, Building A1, CFC, Fifth Settlement, New Cairo
Egypt
Phone: +20 2 24632300
nextcarehealth.com