Duration of Illness: ........................................................... Other Conditions:....................................................... مدة المرض: ........................................................... شروط أخرى:.......................................................
$◻$$◻$◻\square الأمومة LMP: $◻$$◻$◻\square Maternity LMP: ◻ Maternity LMP:| $\square$ Maternity | | :--- | | LMP: |				Chronic  مزمن
Diagnosis ICD10; Please check ( C ) where appropriate التشخيص ICD10 ؛ يرجى التحقق من (C) عند الاقتضاء
Respiratory System  الجهاز التنفسي		Genitourinary system  الجهاز البولي التناسلي			CNS
					Musculoskeletal system  الجهاز العضلي الهيكلي	Cervicalgia M54.2  ألم عنق الرحم M54.2
Endocrine Metabolic  الغدد الصماء الأيضية					Eye & adnexa  العين و adnexa
		Skin & subcutaneous tissue الجلد والأنسجة تحت الجلد
					Ear & mastoid  الأذن والخشاء
				Hair Loss L65.9  تساقط الشعر L65.9		Otitis Media H66.9  التهاب الأذن الوسطى H66.9
						Otitis Extema H60.9  التهاب الأذن Extema H60.9
Digestive System  الجهاز الهضمي		Circulatory System  الدورة الدموية		Angina pectoris 120.9  الذبحة الصدرية 120.9
					Others  الاخرين
						الحالات التي تنشأ في فترة الفترة المحيطة بالولادة P96.9 التشوهات الخلقية Q89.9 Conditions originating in the perinatal period P96.9 Congenital malformations Q89.9 Conditions originating in the perinatal period P96.9 Congenital malformations Q89.9| Conditions originating in the perinatal period P96.9 Congenital malformations | | :--- | | Q89.9 |
	Immunity D89.9  المناعة D89.9			Varicocele 186.9  دوالي الخصية 186.9
Blood Immunity  مناعة الدم						Infertility, Female N97.9 العقم, أنثى N97.9
Cost  كلف
	Out Patient Service (Description) خدمة العيادات الخارجية (الوصف)		Cost  كلف	Code  رمز	الأدوية الأدوية Medications Medications Medications Medications| Medications | | :--- | | Medications |
				$◻$$◻$◻\square $◻$$◻$◻\square
التاريخ المتوقع للإجراء: 11 Expected Date of Procedure: 11 Expected Date of Procedure: 11| Expected Date of Procedure: | | :--- | | 11 |
أقر بموجب هذا بأن جميع المعلومات المذكورة صحيحة وأن الخدمات الطبية المعروضة في (الموقعين أدناه ، يعلنون بموجب هذا ما يلي: أعطي تفويضا كاملا لشركة التأمين و / أو صاحب العمل أن هذا النموذج قد تم الإشارة إليه طبيا وضروريا لإدارة هذه الحالة. د. حسام علي (A00097) توقيع الطبيب وختمه: ......................................... بات: 11 5 لتر لديه ومن ثم / المتأخر من hergungar و vider للكشف عن وتوفير التأمين Comapny و / أو kg هم orctrol يتم الاحتفاظ بها في السجلات الطبية والنسخ المصورة منه $$$$qquad\qquad الاسم: التوقيع hereby certify that ALL information mentioned are correct & that the medical services shown on (the undersigned, hereby declare the following: I give full authorization to the insurance Company and/or employer this form were medically indicated & necessary for the management of this case. Dr. HOSSAM ALY (A00097) Physician Signature & Stamp: ......................................... Pate: 11 5 lof has Hence/ reduest fom the hergungar and vider to reveal and provide the insurance Comapny and/or kg them orctrol are held in their fies and medical records and photocopies of it $$$$qquad\qquad Name: Signature hereby certify that ALL information mentioned are correct & that the medical services shown on (the undersigned, hereby declare the following: I give full authorization to the insurance Company and/or employer this form were medically indicated & necessary for the management of this case. Dr. HOSSAM ALY (A00097) Physician Signature & Stamp: ......................................... Pate: 11 5 lof has Hence/ reduest fom the hergungar and vider to reveal and provide the insurance Comapny and/or kg them orctrol are held in their fies and medical records and photocopies of it qquad Name: Signature| hereby certify that ALL information mentioned are correct & that the medical services shown on (the undersigned, hereby declare the following: I give full authorization to the insurance Company and/or employer this form were medically indicated & necessary for the management of this case. | | :--- | | Dr. HOSSAM ALY (A00097) | | Physician Signature & Stamp: ......................................... | | Pate: | | 11 | | 5 lof has Hence/ reduest fom the hergungar and vider to reveal and provide the insurance Comapny and/or kg them orctrol are held in their fies and medical records and photocopies of it $\qquad$ | | Name: | | Signature |

Duration of Illness: ........................................................... Other Conditions:....................................................... "◻ Maternity LMP:" https://cdn.mathpix.com/cropped/2025_07_28_d25cd70070310bf76b83g-1.jpg?height=37&width=39&top_left_y=802&top_left_x=872 Chronic https://cdn.mathpix.com/cropped/2025_07_28_d25cd70070310bf76b83g-1.jpg?height=34&width=36&top_left_y=800&top_left_x=1522 Diagnosis ICD10; Please check ( C ) where appropriate Respiratory System Genitourinary system https://cdn.mathpix.com/cropped/2025_07_28_d25cd70070310bf76b83g-1.jpg?height=34&width=34&top_left_y=876&top_left_x=877 CNS https://cdn.mathpix.com/cropped/2025_07_28_d25cd70070310bf76b83g-1.jpg?height=33&width=33&top_left_y=873&top_left_x=1508 Musculoskeletal system Cervicalgia M54.2 Endocrine Metabolic Eye & adnexa https://cdn.mathpix.com/cropped/2025_07_28_d25cd70070310bf76b83g-1.jpg?height=46&width=35&top_left_y=1310&top_left_x=1508 Skin & subcutaneous tissue Ear & mastoid Hair Loss L65.9 Otitis Media H66.9 Otitis Extema H60.9 https://cdn.mathpix.com/cropped/2025_07_28_d25cd70070310bf76b83g-1.jpg?height=50&width=31&top_left_y=1627&top_left_x=1510 Digestive System Circulatory System Angina pectoris 120.9 Others "Conditions originating in the perinatal period P96.9 Congenital malformations Q89.9" Immunity D89.9 Varicocele 186.9 Blood Immunity Infertility, Female N97.9 Cost Out Patient Service (Description) Cost Code "Medications Medications" ◻ ◻ https://cdn.mathpix.com/cropped/2025_07_28_d25cd70070310bf76b83g-1.jpg?height=37&width=1616&top_left_y=2348&top_left_x=223 "Expected Date of Procedure: 11" "hereby certify that ALL information mentioned are correct & that the medical services shown on (the undersigned, hereby declare the following: I give full authorization to the insurance Company and/or employer this form were medically indicated & necessary for the management of this case. Dr. HOSSAM ALY (A00097) Physician Signature & Stamp: ......................................... Pate: 11 5 lof has Hence/ reduest fom the hergungar and vider to reveal and provide the insurance Comapny and/or kg them orctrol are held in their fies and medical records and photocopies of it qquad Name: Signature" | Duration of Illness: ........................................................... Other Conditions:....................................................... | | | | | | | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | $\square$ Maternity <br> LMP: | | |  | Chronic | |  | | Diagnosis ICD10; Please check ( C ) where appropriate | | | | | | | | Respiratory System | | Genitourinary system |  | | CNS |  | | | | | | | Musculoskeletal system | Cervicalgia M54.2 | | Endocrine Metabolic | | | | | Eye & adnexa |  | | | | | | | | | | | | Skin & subcutaneous tissue | | | | | | | | | | | | | | | | | | | Ear & mastoid | | | | | | | Hair Loss L65.9 | | Otitis Media H66.9 | | | | | | | | Otitis Extema H60.9 | | | | | | | | | | | | | | | |  | | | | | | | | | | Digestive System | | Circulatory System | | Angina pectoris 120.9 | | | | | | | | | | | | | | | | | | | | | | | | | Others | | | | | | | | | Conditions originating in the perinatal period P96.9 Congenital malformations <br> Q89.9 | | | | | | | | | | | | | | | | | | | Immunity D89.9 | | | Varicocele 186.9 | | | | Blood Immunity | | | | | | Infertility, Female N97.9 | | Cost | | | | | | | | | Out Patient Service (Description) | | Cost | Code | Medications <br> Medications | | | | | | | | | | | | | | | | | | | | | | | $\square$ $\square$ | | | | | | | | | | | | | | | |  | | | | Expected Date of Procedure: <br> 11 | | | | | | | | hereby certify that ALL information mentioned are correct & that the medical services shown on (the undersigned, hereby declare the following: I give full authorization to the insurance Company and/or employer this form were medically indicated & necessary for the management of this case. <br> Dr. HOSSAM ALY (A00097) <br> Physician Signature & Stamp: ......................................... <br> Pate: <br> 11 <br> 5 lof has Hence/ reduest fom the hergungar and vider to reveal and provide the insurance Comapny and/or kg them orctrol are held in their fies and medical records and photocopies of it $\qquad$ <br> Name: <br> Signature | | | | | | |

Explanation of Benefits  شرح الفوائد

Transaction Date: 12/07/2020 تاريخ المعاملة: 12/07/2020

Invoice Number:  رقم الفاتورة:

Diagnosis :  التشخيص:

- Pregnancy confirmed  - تأكيد الحمل

Detailed Bill  مشروع قانون مفصل

Med File  ملف Med

Cons. Fees:  سلبيات الرسوم:

0.00 KD  0.00 د.ك

Service  خدمة

Item  بند

Unit Price  سعر الوحدة

Type  نوع

Qty Claimed  الكمية المطالب بها

Curr  كور

Total Claimed  إجمالي المطالبات المطالب بها

Qty Appr.  الكمية Appr.

Total Appr.  إجمالي Appr.

Disc.  القرص.

CONSULTANT

1- Office Consultation , KD30/(Consultant) 1- استشارات مكتبية ، 30 د.ك / (استشاري)

30.00

1 KD  1 د.ك

30.00

1

30.00

Summary  ملخص

Patient Share  حصة المريض

Total Claimed  إجمالي المطالبات المطالب بها

30.000

KD

Excess Deductile  التخمين الزائد

ductible  قابل للأنابيب

3.000

KD

إجمالي الخصم المعتمد 30.000 د.ك Total Approved 30.000 KD Discount Total Approved 30.000 KD Discount| Total Approved 30.000 | | :--- | | KD | | Discount |

Exceeding Limitation  تجاوز الحدود

0.000

KD

Uncovered Items  العناصر المكشوفة

0.000

Ins Share  مشاركة Ins

0.000 د.ك 0.000 د.ك 0.000 KD 0.000 KD 0.000 KD 0.000 KD| 0.000 | | :--- | | KD | | 0.000 KD |

Net Amount  المبلغ الصافي

27.000

KD

Total Patient Share  إجمالي حصة المرضى

3.000

KD

Transaction Date: 12/07/2020 Invoice Number: Diagnosis : - Pregnancy confirmed Detailed Bill Med File Cons. Fees: 0.00 KD Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc. CONSULTANT https://cdn.mathpix.com/cropped/2025_07_28_d25cd70070310bf76b83g-2.jpg?height=34&width=38&top_left_y=2245&top_left_x=699 1- Office Consultation , KD30/(Consultant) 30.00 1 KD 30.00 1 30.00 Summary Patient Share Total Claimed 30.000 KD Excess Deductile ductible 3.000 KD "Total Approved 30.000 KD Discount" Exceeding Limitation 0.000 KD Uncovered Items 0.000 Ins Share "0.000 KD 0.000 KD" Net Amount 27.000 KD Total Patient Share 3.000 KD | Transaction Date: 12/07/2020 | | Invoice Number: | | | | | | | | | | | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | Diagnosis : | - Pregnancy confirmed | | | | | | | | | | | | | Detailed Bill | | Med File | | | Cons. Fees: | | | 0.00 KD | | | | | | Service | | Item | | Unit Price | Type | Qty Claimed | Curr | Total Claimed | Qty Appr. | | Total Appr. | Disc. | | CONSULTANT |  | 1- Office Consultation , KD30/(Consultant) | | 30.00 | | 1 KD | | 30.00 | 1 | 30.00 | | | | Summary | | | | | Patient Share | | | | | | | | | Total Claimed | | 30.000 | KD | | | Excess Deductile | ductible | | 3.000 | | KD | | | Total Approved 30.000 <br> KD <br> Discount | | | | | Exceeding Limitation | | | | 0.000 | | KD | | | | | | | | Uncovered Items | | | | 0.000 | | | | | Ins Share | | 0.000 <br> KD <br> 0.000 KD | | | | | | | | | | Net Amount | 27.000 | KD | | Total Patient Share | | | | | | | 3.000 | | KD | |

Explanation of Benefits  شرح الفوائد