1.Member information

Patient name

As printed on the insurance card

Card number

Date of birth

Principal name

The main policy member, as printed on their card. Same as the patient if you're the principal.

Email address

Mobile number

2.Medical information

To be completed by the treating doctor. You can leave this empty and have it filled in by hand; the doctor signs and stamps the printed form.

Country of treatment

Date first symptoms were noticed

Provider name and contact informationHospital or clinic name, address and phone number

Physician name and contact information

Symptoms

DiagnosisPrimary and secondary, ideally with ICD-10 codes

Treatment / investigationPrescribed treatments or investigations

3.Claimed invoices

Invoices

Optional — leave empty to write the invoices on the printed form by hand. Up to 6 fit on one form; totals per currency are calculated for you.

Invoice number

Amount

Currency

4.Settlement

Optional — leave empty if your bank details are already on your myNAS profile. For transfers within the UAE, bank name, account holder and IBAN are enough; for transfers abroad, fill in every field.

Settlement currency

Settle by wire transferThe only settlement option on the NAS form

Bank name

Account holder name

IBAN / account number

Use the account number if the destination country has no IBAN

SWIFT code

Bank address

Beneficiary address