ADNIC Reimbursement Claim Form Download

Abu Dhabi National Insurance Company,  ADNIC is, a main multi-line insurance services supplier, has a wide system of branches just as deals and administration focus the nation over. With a devoted group of more than 500 agents, we at ADNIC are focused on giving extensive protection arrangements, to give consolation to its clients.

How to Fill ADNIC  Claim Form:

Must read the following instruction before Filling ADNIC Claim Form.

1. This form needs to be completed by the insured member (Cardholder), only if the provider is not submitting the claim on his behalf.

2. Please read the form carefully and make sure to complete all pertinent information. ADNIC will not be able to process any incomplete Reimbursement Claim Form that lacks proper documentation.

3. Use a separate form for each Member.

4. All the documents including invoices and medical reports should be in either English or Arabic. Documents in other languages must be translated by an official public translator prior to submission.

5. The following documents to be attached to your duly filled Reimbursement Claim Form. • Copy of Medical insurance card and Emirates ID. • Original itemized bill/invoices (dated) and receipts of payment. • Original prescription for medication given by the treating doctor (except for controlled drugs). The validity of the prescription is limited to 60 days and for controlled drugs limited to 3 days in line with the Department of Health – Abu Dhabi. • Investigation requests/reports like laboratory tests, x-rays, etc.

Download ADNIC Claim Form

Complete the form headings by following their instructions:

1. Please write your name & Medical insurance card number as mentioned in the Card.

2. Medical Information – Request your treating doctor to fill up brief medical information about your condition and treatment.

3. Provider Name & Address – Kindly use more than one line if necessary to provide this information about each facility where you were treated.

4. Bill No. – Please write the serial number/reference number printed on the bill/receipt/invoice for each service separately.

5. Service Date – State date of treatment for each service against each bill.

6. Description of services – State type of service like consultation/Pharmacy/Investigations/Physiotherapy/Dental/ Hospitalization.

7. Amount – State the exact amount as appears on the invoices.

8. Total – Total amount of all the invoices submitted with this form for reimbursement from ADNIC. 9. Currency – Name of the currency in which actual payment was made. 10. If treatment is due to a road traffic accident,, a police report is required to be submitted with this form. 11. Declaration: Kindly write your name, signature, date, contact number, and relationship to the cardholder.

Author: UAE INSURE

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