PRE - APPROVAL FORM

Ref No: KMC-


P.O.Box: 52001, Dubai, U.A.E.
Tel: +971 4 3705959
Fax: +971 4 3705700
Helpline: +971 50 8039139
info@ecareinternational.net
A. ADMINISTRATION
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Policy No : Patient Name:
Policy Expiry:              (DD)/              (MM)/            (YYYY) Date of Birth:             (DD)/             (MM)/            (YYYY)
Membership No: Mobile No: Gender:    M   |   F
Group/Company Name: Date of Visit:
Medical Provider Name: Date of Treatment:
B. MEDICAL SECTION

Medical History:

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First Date of Symptom: Work Related Injury:           Yes                  No

Diagnosis/Medical Condition:

 

IF SPECALIST REFERRAL REQUIRED
              
Yes                No

Proposed Treatment which needs approval:

C. PRE-AUTHORIZATION : (FOR E-CARE USE ONLY)

Details of Proposed Treatment/Surgery/Medicine:

Estimated Cost:
As Per Related Documentation:
           Approve                           Not Approve
Reference No:

E-Care Stamp & Date:

 

I/We the undersigned, hereby declare that the particulars given herein are in every respect true and complete.
Doctors Name :
I hereby authorise the Medical Practitioner, Hospital/Clinics, Pharamcy, Lab to claim for me/my dependent (in case of children below 16 years) the medical service expenses and also to provide treatment details to E-Care International. I also confirm that if there is utilisation excess or charges not covered in the policy, it will be borne by me/my company.

Signature:                                                     Date:

Signature:

Stamp:

 

 

Date:
D. SPECIALIST/REFERRAL

Type of Treatment (Specialist):

 

CPT/Service Codes: Itemised Cost

Consultation:

Investigation:
Treatment:
E. PHARMACEUTICAL:
(i) Cost
(ii)
(iii)
I/We the undersigned, hereby declare that the particulars given herein are in every respect true and complete.
Doctors Name :
I hereby authorise the Medical Practitioner, Hospital/Clinics, Pharamcy, Lab to claim for me/my dependent (in case of children below 16 years) the medical service expenses and also to provide treatment details to E-Care International. I also confirm that if there is utilisation excess or charges not covered in the policy, it will be borne by me/my company.

Signature:                                                     Date:

Signature:

Stamp:                                                          Date: