Email for non-humans

General

Step 1

General Previous Next

Name of Procedures Center *

Trade Name (if different)

Legal Entity Name *

Type of Facility *

Cosmetic CenterDay Surgery CenterEndoscopy CenterDialysis CenterCath LabFertility / IVF CenterOncology / Infusion CenterOther

Other Facility Type

Year Established

Date of Commencement of Operations

Accreditation

Step 2

Accreditation Previous Next

Facility License Number *

License Expiry Date *

Issuing Authority *

Accreditation Status

• Accredited
• Not Accredited
• In Process

Accrediting Body

Accreditation Expiry Date

Contact

Step 3

Contact Previous Next

Registered Address *

Country

Saudi ArabiaUnited Arab EmiratesQatarKuwaitOmanBahrainLebanon

City

Postal Code

Telephone

Mobile

Email *

Website

Emergency Contact Number

Ownership

Step 4

Ownership Previous Next

Ownership Type *

Sole ProprietorshipPartnershipLLCCorporationNGO / Other

Owner / Company Name *

Medical Director Name *

Medical Director Specialty

General Manager / Administrator

Authorization

Step 5

Authorization Previous Next

Authorized Signatory Name *

Position *

Telephone

Email *

Services

Step 6

Services Previous Next

Diagnostic / Interventional / Therapeutic Procedures

• Endoscopy / Colonoscopy
• Minor Surgery
• Day Surgery
• Dialysis
• Cardiac Procedures
• Oncology Infusion / Chemotherapy
• IVF / Fertility Procedures
• Pain Management Procedures
• Dermatology / Cosmetic Procedures
• Orthopedic Procedures
• ENT Procedures
• Ophthalmic Procedures
• Urology Procedures
• Other

Other Procedure Service

Support Services

• Laboratory
• Radiology
• Pharmacy
• CSSD / Sterilization
• Recovery Room
• Ambulance Access
• Emergency Response Equipment

Facility

Step 7

Facility Previous Next

Working Hours

Days of Operation

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday
• Sunday

Gallery

Gallery Previous Next

Gallery

Upload Images

Upload up to 4 images

Upload

Billing

Step 8

Billing Previous Next

Billing Contact Person *

Position

Telephone

Email *

Preferred Claim Submission Method

• Portal
• Email
• Physical Submission
• API / Electronic Integration

Tax Registration Number / VAT Number

Bank Name

Account Name

IBAN / Account Number

SWIFT Code

Documents

Step 9

Documents Previous Next

Please attach copies of the following

• Valid facility license
• Accreditation certificate
• Trade license / registration certificate
• List of physicians with valid licenses
• Medical director license
• Professional indemnity / malpractice insurance
• Facility profile / brochure
• Rates / tariff schedule
• Bank details certificate / cancelled cheque
• Tax registration certificate
• Other

Other Document

Upload Supporting Documents

File name:

File size:

Add File

Declaration

Step 10

Declaration Previous Next

Declaration Confirmation *

AgreedNot yet

I / We hereby certify that the information provided in this form and all attached documents are true, correct, and complete to the best of my / our knowledge. I / We agree to notify the insurance company of any changes in licensing, accreditation, ownership, management, services, or legal status.

Authorized Signatory Name *

Signature

Stamp

Date *

Submit