Claim form Submit my claim Claims Form YOUNA IHS Personal information Name * First Name Last Name Your date of birth MM DD YYYY Your member ID * Your phone number Country (###) ### #### Email * We just need now few information about your claim !!! What is the medical or service provider name? What is the medical provider specialty? (Ex: Pediatrician, Dentist..) What is the diagnosis (or medical reason related to this claim - Ex : Headache, Fever..)? Please note that consultation, laboratory, exam, etc… are not diagnosis… What is the treatment or service provided ( Ex : MIR, Consultation, Laboratory test) ? Please confirm the invoice reference and date? What is the treatment Start date? * MM DD YYYY What is the treatment End date? * MM DD YYYY What is the invoice amount? * $ Thank you!
