A’awen – Treatment Support Request Form

Please take some time to fill up the form for us to process your application

Applicant Name :

Applicant Phone Number :

Applicant Email :

Date :

PERSONAL INFORMATION

Patient Name :

Nationality :

Medical Facility File Number ( if any ):

Maritial Status :

Patient Phone Number :

Address :

INCOME ( AED/MONTHLY )

Total Income : .00 AED

Commitments :

Total Family Members :

FINANCIAL & FAMILY BACKGROUND

DETAIL OF SUPPORT REQUIRED

APPLICATION DOCUMENTS REQUIRED

Please submit the below documents together in one PDF file in the same order as listed below (1-7):

1. A written letter explaining the health, social and financial status.
2. Medical report with treatment plan (issued within last 30 days).
3. Estimated cost letter from the hospital (issued within last 7 days).
4. Salary certificate from the workplace of the patient or primary income earner (or equivalent).
5. Bank statement for the last 6 months of all bank accounts (or equivalent).
6. Lease agreement, or the title dead if the person is the owner of the residence.
7. Copy of the passport, residency, and Emirates ID card of the patient, the primary income earner and the rest of the family members.

Note:

We only accept applications for treatment at government hospitals.

If all the documents are not provided as specified and in the required order (1-7) we are unable to process the application.

Upon receiving all the required documents, the file will be sent to the committee and you may be asked to provide additional documents to complete the application.In the event that the application is not completed within 7 days, the application will not be processed and closed without notice.

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