thiqa insurance claim form

Thiqa Reimbursement Claim Form

Thiqa Daman Insurance Hospital and Dental Claim form is required by your doctor or Hospital staff for filling of Claim against your treatment and Regular Check-up. If you are intended to get Reimbursement payment via wire transfer you need to fill in beneficiary name, bank name, branch, account number, bank address, and IBAN number.

Instruction for filling Thiqa Claim Form

Please write your name & the Thiqa card number as mentioned on the Thiqa Card.

  • Please indicate the reason(s) for
  • Provider Name and Address: Kindly use more than one line to provide information on each facility where you were
  • Bill No.: Please write the serial/reference number printed on the bill/ receipt/ invoice for each service separately.
  • Service Date: Kindly write the start date of treatment for each service against each bill.
  • Description of Service: Kindly mention the type of service received such as Consultation
  • /Pharmacy / Investigations /Physiotherapy/Dental /Hospitalization.
  • Amount: Kindly mention the exact amount as it is shown on the invoices.
  • Total: Kindly mention the total amount of all the invoices submitted with this form for reimbursement from Daman.
  • Currency: Kindly mention the currency in which the actual payment was made in the event that the services were availed outside of the UAE in the event of an emergency.
  • Declaration – Kindly write your name, signature, date, contact number, and relationship to the cardholder (if applicable).

Download Editable Thiqa Claim Form

 

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