MaxCare Reimbursement Claim


Please fill up the form below to register your reimbursement claim
Submission details:
Submitting Entity *      
Submitted by *      
Member details:
Emirate ID *
Card Number *
Name of Member *
Mobile No *
Mobile No (Alternate) *
Email *
Reimbursement Claim details:
Chief complaint * Treatment Start Date *
Provider Name * Treatment End Date (Fill only in case of In-Patient admission)
Approval Code Treating Doctor's Name *
Reason For Reimbursement * Claimed Amount *(AED)
Emergency Case * YES  NO
Is approval taken/intimation given for reimbursement claim? * YES  NO
Beneficiary Name *
Account Number IBAN Number
Invoice details:
S.No. Name of the Service Details Amount (AED)
1
Add
ATTACH CLAIM SUPPORTING DOCUMENTS:
Claim Form *  
Member's MaxCare CARD COPY *  
Invoices *  
Reports/Investigations *  
Discharge Summary (Mandatory in case of In-Patient)  
Other Documents (If any)  
 I hereby attach the CARD COPY and authorize any Health care Provider, Insurer, Employer or other organization to release any information regarding my medical condition & history to Maxcare ME for determining insurance benefits.
NOTE : Please upload Scanned Documents in PDF or JPEG format.
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