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Moving from meeting to meeting. : +971 4 3900710 Fax: +971 4 3908600 E-mail: info@mednet-uae.com Web: www.mednet-uae.com Strictly Confidential – Contains Medical Information.

Invoices should be attached with receipts/ paid stamps. Cigna® and Cigna® (Cigna) are registered service marks of Cigna Corporation and/or one of more of its subsidiaries. .ط ... answers and all documents submitted with this Claim form are complete and true.

Dear Member, In order to facilitate prompt settlement of your claims, MedNet is providing the option of submitting your cash (reimbursement) claims online. Whether you’re an employer or employee, Cigna Envoy™ is packed with powerful tools that make managing care easier. Cigna is a global health service company dedicated to helping people improve their health, wellbeing and peace of mind. Submitting a reimbursement claim via your private area is very straightforward. Yes No IF YES, PROVIDE THE NAME OF THE HEALTH INSURANCE CARRIER, EFFECTIVE DATE OF COVERAGE AND POLICY NUMBER The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a standard #10 window envelope. Documents to be submitted include: A break-down of receipts for payments made (cost per service to be shown). The claim form has to be stamped and signed by the treating practitioner and by you. Please fold the form using the ‘tick-marks’ printed in the margin. Just click on “Submit a reimbursement claim” and the system will guide you through the different steps and remind you of all the documentation you need to attach to enable us to process your reimbursement claim. And one of the ways we do that is through Cigna Envoy. *Claims incurred in the United Arab Emirates and submitted by the member to SAICO are only reimbursable in local currency. MedNet UAE FZ L.L.C. Box 500259, Dubai Internet City, Dubai – UAE Tel. *** If your bank is within the EU, or if your specific country requires an IBAN (e.g. Treatment availed outside UAE - For reimbursement of medical expenses incurred outside UAE, claim documents should be received at MedNet within 90 days from date of treatment. Not To Be Duplicated or Handled By Unauthorized Personnel Reimbursement Form Card Holder’s Name: Card No. B. Supporting documents might include medical reports, laboratory test results, ultrasound reports, and referral letters. Whether you’re at work or relaxing at home, you can manage your plans from your mobile or laptop.

A. Employment with Cigna, including employment within the LDP program, is at-will; that is, it is not for a specified period of time and can be terminated at any time for any reason, with or without cause or notice, by me or by Cigna.

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