INCORPORATED IN ABU DHABI IN 1972 WITH PAID UP CAPITAL OF DHS 375,000,000, SUBJECT TO THE PROVISIONS-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient’s name and Health Card number/Emirates ID number in the designated fields.
3. Fill in the Group member’s name and specify the reason for not using listed Healthcare facilities. Choose from options like Emergency or Elective.
4. Provide detailed medical information as required by your treating doctor, including condition requiring treatment, visit date, onset and duration of illness, and treatment details.
5. Complete the section for Name & Address of the Hospital/Clinic along with Bill No., Treatment Date, and Description of Services.
6. Indicate if the case is work-related and whether it is covered by another insurance. Provide necessary details if applicable.
7. In the Declaration section, confirm that all information provided is true and complete. Sign and date where indicated.

Start filling out your form online for free today!