NANO eAuthorize Provider

Provider Name *

Provider Type *

Tax Registration Number

E-Claim Type *

Health Authority License Number

Submission Type *

Address *

Country *

City *

Contact No *

(999) 999999999

Email Address *

Contact Details of the Authorized Signatory

Full Name *

Contact No *

(999) 999999999

Email Address *

Insurance Manager

Full Name *

Contact No *

(999) 999999999

Email Address *

Insurance Assistant Manager

Full Name

Contact No

(999) 999999999

Email Address

Accounts Manager

Full Name *

Contact No *

(999) 999999999

Email Address *

Accounts Assistant Manager

Full Name

Contact No

(999) 999999999

Email Address

Bank Account Details

Bank Name

Branch

Bank Account Number

Beneﬁciary Name

Country

IBAN Number

Swift Code

City

Tariff Upload

Upload Tariff Details*

Select file Change Remove

Download template file, fill-in and upload.
File types allowed: .xls, .xlxs

Required Documents

Supporting Documents*

Add files...

Please attach legal supporting documents
File types allowed: .xls, .xlsx, .doc, .docx, .pdf, .png, .jpg

‹ ›