National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)

Doc Ctrl No.: F/AUTH-024 Version No.: 1 Revision No.: 0 Date of Issue: 26.07.2012 Page No(s).: 1 of 2

Appeal/Exception Request Form

Please read the instructions and guidelines shown overleaf before completing the form. Section 1, 2, 3 and 5 to be filled by the card holder only and section 4 to be filled by the treating Doctor.

1. Card Holder’s Information

Card Holder’s Name: (Exactly as printed on the card) Daman Card No.:

Member E-mail Address: * Mobile No.:

Member Address:

2. Reason for Appeal/ Exception

Type of Denial(Kindly indicate)

Denied decision for service not yet received (continue with step 1, 3)

Denied decision for service rendered claim (continue with step 1,2,3,4)

Type of request (Kindly indicate) Appeal Exception Formulary inclusion

Claim reference number:

What decision are you appealing/requesting for exception?

Explain why you believe the claim or service should be covered:

3. Claims Payment

Wire Transfer (Please provide your bank account details) :

Beneficiary Name * Bank Name * Account Number *

Full Beneficiary Address Branch IBAN*

Please fill-up a separate request form if cheque payment is preferred.

4. Medical Information (To be filled by treating Doctor for all outpatient treatment. For cases like hospitalization, procedures, surgeries- a detailed medical report is required to be submitted along with this form)

Medical History / Chief Complaints:

Visit Date:

Diagnosis:

Explain why you believe this service should be covered:

I declare that I have attended to this patient and that the particulars given are true and correct to the best of my knowledge.

Name & Signature of the Doctor: Date: Stamp:

5. Claim Information (Refer to Appendix A. - General Instructions)

Reason for not using Daman’s listed Health facilities (Kindly indicate)

Emergency Family Doctor Preferred Personal Choice Service Not Available On Vacation/Business Trip Outside UAE

Others; Please specify:

Name & Address of the Hospital / Clinic Bill No. Treatment Date Description of Services Amount

Currency (If treatment availed outside UAE)

TOTAL:

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)

Doc Ctrl No.: F/AUTH-024 Version No.: 1 Revision No.: 0 Date of Issue: 26.07.2012 Page No(s).: 2 of 2

Appeal/Exception Request Form

6. Declaration

I, the undersigned, declare that all of the information as stated above is correct and that the reimbursement claim requested are for the expenses as paid by me for the treatment of my covered condition as stipulated above.

I, the undersigned, declare that all of the information as stated above is correct and that the authorization appeal/exception requested are

for the medical diagnoses as stipulated above.

I, the undersigned do hereby authorize the National Health Insurance Company – Daman (PJSC) (“Daman”) to have access to and take

copies of my medical records from 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 in relation to any sickness or accident, any treatment, examination, advice or hospitalization or any other information as stated in this form.

I am fully aware that any person who intentionally makes any false and/or misleading statements and/or information to obtain

reimbursement/authorization/exceptional approval from Daman is subject to investigation and shall be referred to the competent authorities in the United Arab Emirates.

Name Signature Date Mobile No. Relationship to the Card Holder

Appendix A: General Instructions

1. In compliance with the instructions with the Health Insurance Law of the Emirate of

Abu Dhabi and the federal laws of the United Arab Emirates, all information related to

the form shall be treated as strictly confidential and shall not be disclosed to any

third party.

2. This form can be used for all types of medical plans and has to be completed by the insured

member (card holder)/ insured member’s father, mother or legal guardian (in the event that

the insured member is below the age of 18 or legally incapacitated), only if provider is not

submitting the form on his behalf.

3. Please use a separate form for each insured member (card holder).

4. Please read the form carefully and make sure to complete all pertinent information.

Daman will not be able to process any incomplete Appeal/Exception Request Form without

complete documentation as listed below:

Essential Documents:

• Copy of Daman card

• Copy of Emirates I.D. (or other official ID e.g.

Passport, Driving License etc.)

• Copy of prescription

• Original itemized Invoices with date /payment

receipt

• Medical Declaration from physician Additional Requirements for

Treatment availed outside the UAE Passport copy with the entry/exit stamp or any other proof

must be provided.

Note: Please retain copies of receipts and documents enclosed with this form prior to

submission, as Daman will not return the original documents.

5. Payment Preference:

- Wire Transfer: All information marked with a star should be provided to grant reconciling to

the correct account.

- The wire transfer payment will be deposited into the principle account

6. You will be notified of the appeal decision after thirty (30) calendar days from the submission

date.

7. Please note that the claim might take an additional five (5) working days if submitted in a

foreign language (other than English/Arabic).

8. To ensure efficient and prompt settlement of your claims, please submit all the above required

documents directly to Customer Support Desk in any of Daman’s Abu Dhabi Branches for

convenience.

If you have any question or need assistance in filling this form,

Please call 800 4 32626 or 800 4 DAMAN within UAE or +971 2 6149555 Outside UAE