PRE-AUTHORIZATION REQUEST FORM ID/Passport
Part 1 Insured Details
Insured Name: Policy No.:
Mobile No.: E-mail Id If Group Policy, Company Name: Employee id
Patient Name:
Part 2 Patient Details
Membership Number:
yrs DOB:
Age:
Patient Mobile No.:
dd/mm/yy
Gender:
Patient Email id:
Relation with insured:
Self
Spouse
Mother
Father
Daughter
Son
Others
Address: City;
Pin Code
Attendant Name: Attendant Mobile no.:
Attendant email id
Hospital Name:
Hospital Code:
Hospital Address: City:
Pin Code Treating Doctor's Details
Contact Details (Hospital Employee) Name:
Name: Dr.
Telephone no./Mobile no.
Qualification:
Fax No.:
Registration No.:
E-mail Id
Mobile No.: Approval request (please tick appropriate box)
Part 3 Service Provide Details
Elective Treatment In-Patient
Day-Patient
Out-Patient surgery
Physiotherapy
Other Treatment Emergency admission
Accident
Please provide full details of nature of illness and Treatment:
Please provide details of cause, date and place of Accident:
Was a third party involved? If yes, please give details:
Mortal remains
Psychiatric Treatment
AIDS
Others
PET
Maternity
Male
Female
1) Nature of illness/disease with presenting complaints: 2) How did injury occur: 3) Relevant clinical findings: 4) Past history of present ailment, if any: Days
a. Duration of present ailment: b. Date of first consultation:
dd/mm/yy
c. Any past illness relevant to present ailment.
Part 4 The Illness/Disease
5) Provisional Diagnosis: 6) Proposed line of treatment:
Medical Management
Surgical Management
7) If Medical Management, provide details:
Intensive care
Route of drug administration
8) If Surgical, name of surgery: 9) If other treatments provide details: 10) Injury/disease caused due to substance abuse/alcohol consumption:
Yes
No
Test conducted to establish this: Yes/No, attach report. 11) In case of Maternity:
G
P
L
Part 5 Treatment Details
12) Past history of any illness:
A. Date of delivery:
dd/mm/yy
If yes, since
a. Diabetes
dd/mm/yy
b. Hypertension
dd/mm/yy
c. Heart Disease
dd/mm/yy
d. Br. Asthma/COPD/TB
dd/mm/yy
e. Osteo Arthritis
dd/mm/yy
f. Cancer./Tumor/Cyst
dd/mm/yy
g. HIV or STD
dd/mm/yy
h. Any h/o alcohol/substance abuse
dd/mm/yy
i. Any other Ailment/Surgery
dd/mm/yy
a. Was a third party involved? If yes, please give details:
b. Need hospitalisation:
Yes
No
Authorization / Declaration I hereby agree, affirm and declare that, the above details provided with respect to complaints and past illnesses are true, complete and correct to the best of my knowledge and belief. I understand and agree that in the event that any of the details are found to be untrue or incorrect, GENERAL HOSPITALS may refuse my preauthorization request. I further understand and agree that I shall be responsible and agree to bear the medical/hospitalization expenses in any of the aforesaid event /circumstances. I hereby provide my consent and authorize GH to seek any medical information from any hospital/Medical Practitioner who has at any time attended on the insured/patient person. Patient Signature:
Treating Doctor's Signature:
Date & Place:
Stamp of Hospital:
Instructions: 1.GH will not be held liable for payment in the event of any discrepancy in information provided by the hospital at the time of admission & network settlement (in final document submission) 2. If any details provided are insufficient / incorrect, there may be a delay / denial of pre - authorization (cashless) request. All queries raised by the GH should be replied within 24 hours. 3. Any change in the diagnosis / Treatment plan / Length of stay should be intimated to the GH before discharge of the patient assured. 4. Any request for authorization / enhancement made by the hospital after discharge of the patient assured will not be considered. Please ensure this information is provided 24 hours prior to admission, test or treatment. Failure to complete this information in full could delay our ability to provide a decision. Return this document to the following: Email: pre-authorisation@ .com or fax:
.