Form Gr 68585 8 Rhpf – Fill Out and Use This PDF

The Gr 68585 8 Rhpf form is a specialized document integral for policyholders under the Aetna Global Benefits umbrella, intending to file a claim related to healthcare services received. Designed for Royal & SunAlliance policies specifically issued in the United Arab Emirates, it mandates comprehensive completion to facilitate the accurate and timely processing of claims. The form not only streamlines the submission for reimbursement or direct payment to healthcare providers but also sets forth guidelines for the provision of necessary documentation. To ensure your claim is handled efficiently, click the button below to begin filling out your form.

Get Form Now Download PDF

Form Gr 68585 8 Rhpf PDF Details

Navigating through healthcare claims can often feel like a complex journey, especially for policyholders of Royal & SunAlliance in the UAE, administered through Aetna Global Benefits (Middle East) LLC. The Gr 68585 8 Rhpf form serves as a pivotal tool in this process, designed to streamline the submission of claims under AETNA GLOBAL BENEFITS. It is crucial for users to complete the form thoroughly and return it within six months from the initial treatment date to avoid delays. The form encompasses several key sections, including policyholder information, patient details, claim reimbursement preferences, and a crucial declaration part where patients consent to the use of their information for claim processing. Additionally, it features a section exclusively for the medical or dental practitioner's input, ensuring all treatment details are accurately captured. The form requires attentiveness to details like banking information for reimbursements and emphasizes the importance of attaching all supporting documents. Notably, it reminds patients of the necessity for pre-authorization for specific treatments, underscoring Aetna's commitment to a streamlined and efficient claims process. Completing this form accurately is a step towards a smoother experience in managing healthcare claims.

Question	Answer
Form Name	Form Gr 68585 8 Rhpf
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	payee, Dubai, UAE, MRI

Form Preview Example

Regional Healthcare Plan	AETNA GLOBAL BENEFITS
	AETNA GLOBAL BENEFITS
Claim Form

Please ensure Your Claim Form is completed in full and returned within six months of Your initial Treatment. Failure to complete Your form in full will result in the form being returned to You and will hold up the processing of Your claim. Please note Aetna Global Benefits is not responsible for any costs associated with the completion of this form or for any further information/documents requested by Us to assess Your claim. The issuing of this Claim Form is in no way an admission of liability.

This claim form is to be used for Royal & SunAlliance policies, issued in the UAE only.

If You have insufficient space in any section, please provide full details on separate sheet.

Please return this completed form to Us or Your agent.
Aetna Global Benefits (Middle East) LLC	T:	+971 4 438 7600
PO Box 6380	F:	+971 4 428 7101
Dubai	E: MEAServices@aetna.com
United Arab Emirates

Policyholder Information

Policyholder Name	Policy Number

Section A: Patient’s Details – To be completed by the member.

1.	Family Name

2.	First Name and Initials						3. Date of Birth (Day/Month/Year)

4.	Address

5.	Contact Telephone Number		6. Fax/Mobile	7.	Email

8.	Do You hold any other insurance?			9.	Were Your injuries caused by an Accident?
	Yes	No			Yes	No
	If Yes, please provide full details on a separate sheet.				If Yes, please provide full details on a separate sheet.

Section B: Claim Reimbursement – To be completed by the member. It is essential that all information is completed if WE are to complete an international transfer.

Please check one of the following (as applicable):

Please pay Doctor/Treatment Provider.

ii) Bank Transfer to payee below:

Use the bank details on file to send an electronic funds transfer.

Use the bank details below for this claim only.

Use the bank details below for all future claim reimbursements until further notice.

Bank Details - the following information is required in full. AGB will transfer funds at no cost to You however, We encourage You to check with Your bank regarding additional fees they may pass on to You for these transactions.

Please complete this section in BLOCK CAPITAL LETTERS.

Currency in which You wish to be reimbursed:

Name of Accountholder (As it appears on the Bank Statement):

Bank Account Number (or IBAN):

Bank Identification Code/Routing Code:

Routing code type: Bank Name:

SWIFT/BIC Code

CHIPS UID

Federal ABA

Bank Sort ID

Other

Bank Address (include Country):

Bank Telephone Number (including country code):

iii)

Cheque - Payee:

Currency:

Address to which settlement letter should be sent:

Please Retain a Copy for Your Records

Policies issued in the United Arab Emirates (UAE) are issued by Royal & SunAlliance (RSA) and administered by Aetna Global Benefits (Middle East) LLC, an Aetna Company Aetna Global Benefits (Middle East) LLC. Registered address: 416, Oud Metha office, PO Box 6380, Dubai, UAE. Aetna

GR-68585-8 RHPF (9-09)

Page 2

Section C: Declaration

“I declare that all information, to the best of my knowledge, provided on this Claim Form is truthful and correct. I also understand that this declaration gives permission to Aetna Global Benefits and their appointed representatives to approach any third party for information required to complete their assessment of this claim including, but not limited to, my current and previous Medical Practitioners. I declare and agree that the personal information collected or held by Royal & SunAlliance, whether contained in this claims form or otherwise obtained may be used by Royal & SunAlliance, or disclosed to or transferred to any organisation within the Aetna Group (of Companies), their suppliers and partners, Worldwide for the purpose of 1) providing on-going insurance and customer service, 2) processing and giving effect to credit card payment, 3) generating statistics to provide marketing material in respect of insurance-related services of Royal & SunAlliance or it’s associated companies and 4) processing claims or analysing the insurance.”

Patient’s Signature (If patient is under 18 years of age, Parent or Guardian must sign.)

Date (Day/Month/Year)

Section D: Claims Information – To be completed by the patient’s MEDICAL PRACTITIONER or DENTAL PRACTITIONER.

1.Details of Medical Condition Requiring Treatment: (Please provide the precise diagnosis, if known.)

2.Underlying Cause

3.If this claim is for maternity, please advise whether the pregnancy is as a result of any form of assisted conception.

4.How long has this condition existed?

5.When did the patient first become aware of any symptoms prior to seeking medical ADVICE?

6.Date of first consultation with any practitioner for this condition.

7.Has this, or any similar condition previously been suffered from?

8.Please confirm the likely period of TREATMENT and prognosis (if known):

9.Name and address of referring Doctor/Dentist (Please complete only if the patient has been referred to YOU.)

10.Please detail any diagnostic tests performed and attach the results.

11.This question relates to Dental Treatment only. Is this claim for a routine check-up?

Yes

Section E: Medical Practitioner or Dental Practitioner Details – To be completed by the patient’s MEDICAL

PRACTITIONER or DENTAL PRACTITIONER.

**IMPORTANT** - Please ensure:

1.All original receipts and prescriptions are attached.

2.The Claim Form is completed in full.

3.The declarations are signed and dated.

4.All laboratory tests are attached.

5.The diagnosis and underlying cause have been confirmed.

6.If the claim amount exceeds USD 60,000 per year We are required to carry identity checks of the claimant by collecting their valid photo identity document- passport/ driving license/national identity card or any other photo identity document issued by the Government.

This will ensure that Your claim is reviewed in a timely fashion.

Official Stamp:

Name of Practitioner

Address of Practitioner

Telephone Number

Fax Number

Practitioner’s Signature

Date (Day/Month/Year)

Please Retain a Copy for Your Records

GR-68585-8 RHPF (9-09)

Page 3

Important Note:

Please ensure that all costs for non-Emergency In-Patient/Day-Patient Treatment, all MRI and CT scans are agreed by Us, via Our International Member Service Centre or in writing (fax/email/letter) before any planned Treatment is undertaken. Planned Treatment undertaken without pre-authorisation from Us will not be covered. A verbal confirmation does not constitute pre-approval. If in doubt, please contact the International Member Service Centre, as shown on Your membership card.

PLEASE NOTE: A SEPARATE CLAIM FORM MUST BE COMPLETED FOR EACH CONDITION CLAIMED.

Planned In-Patient and Day-Patient Treatment

In the event of a planned admission on an In-Patient or Day-Patient basis to a Hospital, the following steps must be taken. Payment of all expenses incurred by You will not be recoverable unless You follow these procedures.

i)Contact Our International Member Service Centre as soon as reasonably possible prior to admission giving full details of the condition, proposed Treatment including dates and name of procedure (if known) together with the name of the Specialist and Hospital details. (The telephone number is provided on the back of Your membership card.)

ii)The International Member Service Centre will advise You if they have sufficient information to confirm Your cover. If not, they will advise You what further information is required.

iii)When sufficient information has been made available to appraise Your claim, the International Member Service Centre will verbally confirm the basis of Your cover and will despatch written confirmation to You.

iv)The International Member Service Centre will attempt at all times to make arrangements with the Hospital for all eligible bills to be settled directly. Where this has been arranged, You should send the original Claim Form and any unpaid invoices (if given to You by the Hospital) to Your Aetna Global Benefits Claims Service.

v)Please ensure a new/separate Claim Form for each member, each new Medical Condition and each admission to Hospital, is submitted.

Out-Patient Treatment

If You receive medical Treatment as an Out-Patient, outside of Our Provider Network, Treatment must be paid for in full by You at the time of the appointment and re-claimed from Us. In such circumstances, please ensure that a Claim Form is completed by You and the Medical Practitioner or Specialist. Please remit this to Your Aetna Global Benefits Claims Service with all substantiating proof of Your claim, including but not limited to, the original invoice(s) and proof of payment, prescription and a written diagnosis from the Medical Practitioner.

Please Retain a Copy for Your Records

GR-68585-8 RHPF (9-09)

How to Edit Form Gr 68585 8 Rhpf Online for Free

Dealing with PDF documents online is always quite easy with this PDF tool. You can fill in Oud here effortlessly. To keep our tool on the cutting edge of efficiency, we aim to put into practice user-driven features and improvements on a regular basis. We are always thankful for any feedback - help us with revolutionizing PDF editing. Starting is effortless! Everything you should do is adhere to the next basic steps down below:

Step 1: Click the "Get Form" button in the top area of this page to access our PDF editor.

Step 2: This tool provides you with the opportunity to modify nearly all PDF forms in many different ways. Modify it with personalized text, adjust original content, and include a signature - all when you need it!

If you want to finalize this document, be sure to enter the information you need in every single area:

1. Begin completing your Oud with a number of major fields. Consider all of the important information and ensure not a single thing missed!

Stage no. 1 in filling out aetna 2020 reimbursement form

2. Immediately after this selection of blanks is done, proceed to enter the relevant information in these: Use the bank details on file to, Please check one of the following, Cheque Payee, Address to which settlement letter, Bank Details the following, SWIFTBIC Code, Bank Sort ID, Federal ABA, CHIPS UID, Other, Currency, and Please Retain a Copy for Your.

The best way to fill out aetna 2020 reimbursement form step 2

Those who work with this document generally make some mistakes while filling out Use the bank details on file to in this part. Ensure that you read again everything you enter right here.

3. In this specific step, examine Patients Signature If patient is, Date DayMonthYear, Section D Claims Information To, Details of Medical Condition, Underlying Cause, If this claim is for maternity, How long has this condition, When did the patient first become, Date of first consultation with, Has this or any similar condition, Please confirm the likely period, Name and address of referring, Please detail any diagnostic, Yes, and Section E Medical Practitioner or. These have to be filled in with greatest precision.

How long has this condition, Patients Signature If patient is, and Please detail any diagnostic in aetna 2020 reimbursement form

4. The fourth subsection arrives with all of the following blanks to focus on: Official Stamp, IMPORTANT Please ensure All, confirmed, If the claim amount exceeds USD, This will ensure that Your claim, Name of Practitioner, Address of Practitioner, Telephone Number, Practitioners Signature, Fax Number, Email, and Date DayMonthYear.

Writing section 4 in aetna 2020 reimbursement form

Step 3: Prior to submitting your file, double-check that all blanks were filled out properly. As soon as you’re satisfied with it, click on “Done." Right after starting afree trial account at FormsPal, it will be possible to download Oud or send it through email without delay. The PDF form will also be readily available from your personal cabinet with your every modification. FormsPal guarantees risk-free document completion devoid of personal information record-keeping or any type of sharing. Be assured that your details are secure here!

Form Gr 68585 8 Rhpf – Fill Out and Use This PDF

Form Gr 68585 8 Rhpf PDF Details

Form Preview Example

How to Edit Form Gr 68585 8 Rhpf Online for Free

Form Gr 68585 8 Rhpf isn’t the one you’re looking for?

Related Documents