Medical Reimbursement

Please complete all required fields to submit your reimbursement claim.

Patient & Policy Details

Patient’s Name *

Patient’s Insurance ID No *

Patient’s Emirates ID *

Date of Treatment *

Place of Treatment *

Requested Claim Amount (AED) *

Principal Bank Name *

Principal Emirates ID *

Principal Bank Account No *

Principal IBAN No *

Principal Mobile *

+971

Principal Email *

Upload Documents *

Message *