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Medical Dental Reimbursement Claim Form

This reimbursement claim form requires the employee to provide their details, the patient's medical details certified by a doctor, authorization to obtain medical records to process the claim, and a checklist of required documents. The employee must create a claim ID, submit the completed form with the doctor's signature and stamp, and include original receipts and prescription copies.

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Viet Anh
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5K views1 page

Medical Dental Reimbursement Claim Form

This reimbursement claim form requires the employee to provide their details, the patient's medical details certified by a doctor, authorization to obtain medical records to process the claim, and a checklist of required documents. The employee must create a claim ID, submit the completed form with the doctor's signature and stamp, and include original receipts and prescription copies.

Uploaded by

Viet Anh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Reimbursement Claim Form

Medical / Dental

Requirements: 1. Create a claim ID on HRDirect > Profile > Medical Benefits > Claims > Add > Save > Submit
2. Submit completed claim form with doctor’s signature and stamp
3. Submit supporting documents including original receipts and prescription copies

Section A - Employee Details (* Mandatory Fields)

Claim ID number *

Name of Employee * Staff Number *

Section B – Patient Medical Details (To be fully completed by treating doctor or dentist)

Patient Name DOB

Complaints /
Onset / History

Diagnosis

Planned Treatment

I declare that I am the patient’s treating doctor/dentist and that the Doctor’s stamp
particulars given are to the best of my knowledge true and correct
Signature and Stamp
Signature Date / /

Section C – Patient / Spouse / Guardian Signature (* Mandatory Fields)


I hereby authorise the Emirates Group to obtain any and all medical records, reports and test results, either in original hard-copy form or via
access to electronic data systems, as may be required to validate my claim. I consent to the Emirates Group disclosing my medical records,
reports and test results for the purpose of processing and validating my claim. In addition, I understand any such medical information provided
to the Emirates Group will be accessible to Emirates Group employees (including employees of wholly owned subsidiaries) on the Emirates
Medical Benefits System Employee Portal via confidential log-in.
Signature
Date / /

Section D – Employee Checklist (* Mandatory Fields)


Employee check Documents Submitted For MB use only
 Claim form * 
 Original receipts * 
 Prescription copy * 
 EK referral 
 Breakdown of costs 
 Medical / Lab / Investigation report – LMP date if pregnant 

Category A B C D Processor Date Payable Non-payable

Effect 8 January 2008 Issued 1 November 2016 Page 1 of 1

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