Daman Claim Form

Patient’s Details (To be completed by the Admission Department)

Patient’s Name: (as written on Daman Card):

اسم المريض

Daman Card Number:

رقم بطاقة الضمان

Patient Mobile Number:(Mandatory)

رقم هاتف المريض

Provider’s Name/Code:

اسم/رمز المزود

Physician’s License No:

رقم ترخيص الطبيب:

Date:

تاريخ

Service / Admission Information (To be completed by the Admission Department)

Inpatient

Day Care

Outpatient

Medical Details (To be completed by the Medical Doctor-please do not use abbreviations)

Category: ER

New Visit

Follow-up

Road Traffic Accident

Work Related Accident

Referral

If Referral Please Specify Source:

Chief Complaints:

Diagnosis (ICD-9 Description):

Anticipated Management Plan:

Estimated Cost:

Expected Length of Stay: Days
Day Care Estimated Cost:

Expected Date of Admission/ Service:

Services requiring approval from The National Health Insurance Company – Daman (PJSC)

Admission MRI CT Scan Physiotherapy Home Nursing Endoscopy Psychiatry / Psychotherapy Others
Specify:

Doctor's Signature & Stamp:

Date:

Patient Consent: I, the undersigned hereby authorize the National Health Insurance Company- Daman (PJSC), to obtain all required medical information about my case from the provider upon their request.

Patient Signature:

Date :

Authorization review shall not, in any way, impair treatment timelines. The patient, provider and concerned medical care professionals are liable for all treatment decisions to improve the quality of life of the patient.

This request for authorization does not guarantee payment. Payment is subject to the patient’s eligibility and contract benefits at the time of service.