Wire Transfer (Please provide your bank account details or bank account details of authorized person mentioned in section 5 below): Note: Insurance Club does not impose any additional fees on all payment transactions related to claim reimbursements. Charges may only be applicable based on the internal policies and procedures of the respective bank.
(To be filled by treating Doctor for all outpatient treatment. For cases like hospitalization, procedures, surgeriesdetailed Medical report is required)
I, the undersigned, declare that the information above is correct and that the reimbursement requested is for the expenses paid by me for the treatment of my covered condition. I hereby authorize any Doctor, Hospital, Clinic or Medical Provider; any Insurance Company or any Company, Institution or any other person who has any record or information about me and/ or any of my family members to provide National Health Insurance Company – Insurance Club with the complete information including copies of their records with reference to any sickness or accident, any treatment, examination, advice or hospitalization or any other information required by Insurance Club. Furthermore, I hereby authorize the following to receive information and/or payments related to this claim from Insurance Club on my behalf: Relation/ Capacity: I am fully aware that any person who intentionally makes any false and/or misleading statement and/or information to obtain reimbursement from Insurance Club is subject to penalization.
