Claim Status:Authorized Out-PatientFOB> Claim Ref: W0000908777

Allianz Saudi Fransi Cooperative Insurance Company
Policy:MODERN ARAB CONSTRUCTION CO. LTD.
Policy #:MDN/33290
Member:. Azeem Ahmed Khan / DOB:17/07/1979
Card #: E191-F2C0-C47A-7042 / PIN:
Gender:Male / Married / Iqama#:2388093565
Network:Ded: 20% Max 100 SAR / Class:Class C1
Ded:EN / Green Ltd. Network 1
Valid Until:20/05/2017

ProviderName:Shifa Jizan Polyclinic - Jazan

Insurance Co :Allianz Saudi Fransi Cooperative Insurance Company

TPA Name :SAUDI NEXtCARE

Date of visit :13/08/2016Plan Type :Out-Patient

Patient file No:76376

Dept :

Diagnosis Description:N21.9 Calculus of lower urinary tract, unspecified

Claim Motive:Physical Illness/to be specified under assessment/to be specified under assessment

Chronic / No / Emergency / No
Estimated Cost / 400
BP / 120/80 / Pulse / 72 / Temp / 37 / Resp. Rate / 37 / Onset Date / 10/08/2016

Chief Complaint & Main Symptoms

LOWER ABDOMINAL PAIN PAIN DURING MICTURATION SINCE 3 DAYS PAIN BURNING MICTURATION

Requested Services

Code / Service Description
/ Quantity Claimed / Quantity Approved
X087 / USG / 1 / 1
P01 / MEDICIN / 1 / 1

Authorization Note

SNC Officer: Date:13/08/2016

SNC Comment : / Make sure that the required Service is not included in the list of the services
that need Prior Approval. All Approvals will be subject to Audit and Policy Terms
and Conditions.
Provider Comment : / NEOCIPRO 500MG. VOLTIC 50MG.
SNC Comment : / Make sure that the required Service is not included in the list of the services
that need Prior Approval. All Approvals will be subject to Audit and Policy Terms
and Conditions.

Important:

1-SAUDINEXtCARE will only approve medical charges directly and strictly to the case registered above. The final bill shall remain subject to billing rules, and to our auditing doctors’ approval.

2-SAUDINEXtCARE hereby clearly reserves the right to decline any claim settlement due to misuse, abuse or tentative of fraud related either to the entry of the aforementioned information or to its trueness.

3-Copy of this authorization letter should be attached to the claim on time of claim submission for payment.

4-This form is subject to the terms, conditions, and procedures of the contract signed with SAUDINEXtCARE

5-If you have any questions or require further information please contact our Call Centre 24 hours a day/7 days a week on tel. +966 920003055 or fax on +96638988940.

SAUDINEXtCARE Head Office - Al Khobar - KSA |PO Box 30455 | King Abdallah Road, Al Khobar 31952, KSA

Call Center: | 920003055 | Fax +966 13 8988940

This fax was generated by TATSH - Copyright NEXtCARE © 2009

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