Insurance Claim Request Form

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Insurance Claim Request Form

Submit Insurance Claim Request Form

full name :

ID/Residence Number:

Mobile number:

Email (optional):

Insurance company name:

Insurance card number:

Is the insurance valid?

Have you previously submitted claims with the same company?

Number of paid sessions

Date of first session:

Date of last session:

Would you like us to file the claim on your behalf?

I hereby authorize Rawad Al Amal Physiotherapy Complex to prepare and submit an insurance claim in my name to the insurance company mentioned above. I bear responsibility for the accuracy of the data and attachments and I understand that Rawad Al Amal Physiotherapy is not responsible for the decision to accept or reject the claim by the insurance company.

the date :

the signature :