Authorized Claim Form No: EA0030284907/1 EA0030284907/1

On Behalf Of the Payer : Takaful Emarat Insurance PSC

Provider Name NMC Royal Hospital LLC DXB Ex NMC Hospital LLC User Name
Date & Time 28-Feb-2024 12:36 Fax No 8854274

Patient Information
Patient Name AREL EGE GOZEN Date Of Birth 20-Aug-2020
Policy No. 01-115-01-23-8651500616 Expiry Date 21-Aug-2024
Policy Holder ONUR GOZEN Card No 4541-DC1B-F0A1-7AB4
National ID 784-2020-6828614-9
Product Iridium(D0%P0%C0%)
Identity Card 784-2020-6828614-9

Regulator Member ID I022-002-119747657-01

Medical Information
Consultation Date 28-Feb-2024 Family Of Benefits Out-Patient
Hospitalization Motive Accidental Injury Admission Date 28-Feb-2024
Physician Name Dr Elmarghany Mohammed Physician Specialty Orthopedic Surgery
Length Of Stay 0.0
ER Triage 0

Requested Services
Below Item ( s ) have been approved

Qty Qty
Service Item Description Remarks
Claimed Approved

29065 Application, cast; shoulder to hand (long arm) 1.0 1.0

Estimated Cost (AED) : (312.76)

Authorization Notes
Authorization Form is valid until 29-Mar-2024

approved

Disclaimer
1. NEXtCARE will only approve medical charges directly and strictly related to the case registered above. The final bill shall remain subject to billing rules, and to our auditing doctors’ approval.

2. NEXtCARE hereby clearly reserves the right to decline any claim settlement due to misuse, abuse or tentative of fraud related either to the entry of the aforementioned information or to its trueness.

3. If you have any questions or require further information, please contact NEXtCARE Call Center on tel. no. 24 hours a day/7 days a week.

4. This form is subject to the terms, conditions, and procedures of the contract signed with NEXtCARE.