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ASKRI G I Intimation Form (Printer Friendly ISO Coded)

The Pre-Authorization Form outlines important instructions for hospitals and doctors, emphasizing that no columns should be left blank and listing exclusions from coverage. It requires detailed patient and treatment information, including diagnosis and expected costs. Contact information for the head office and branches is provided for further assistance.

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syedsamariqbal
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16 views1 page

ASKRI G I Intimation Form (Printer Friendly ISO Coded)

The Pre-Authorization Form outlines important instructions for hospitals and doctors, emphasizing that no columns should be left blank and listing exclusions from coverage. It requires detailed patient and treatment information, including diagnosis and expected costs. Contact information for the head office and branches is provided for further assistance.

Uploaded by

syedsamariqbal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PRE-AUTHORIZATION FORM

IMPORTANT INSTRUCTIONS FOR THE HOSPITAL/DOCTOR

1. Please ensure no column is left blank


2. Following are NOT COVERED.
a. Admission for work-up and investigations.
b. Tests and treatment related to infertility.
c. Observations & Rest cures.
d. The difference of charges between the Visiting Doctor and the Panel hospital doctor to be charged
tothe Patient.

FOR ATTENTION CALL - Head Office051-9028192, 0333-5107774. FAX 051-9028219/9272424


Karachi Branch 021-3430670108Lahore Branch 042-35860876

HOSPITAL NAME____AHMED MEDICAL COMPLEX____________________________________________


1. DATE OF INTIMATION: ________________________________________________________________
2. POLICY NO: _________________________________________________________________________
3. COMPANY (PATIENT’S EMPLOYER): _____________________________________________________
4. FOLIO NO. __________________________________________________________________________
5. PATIENT’S NAME. ____________________________________________________________________
6. PATIENTS CNIC # / Form ‘B’: ___________________________________________________________
7. EMPLOYEE NAME: ___________________________________________________________________
8. EMPLOYEE CNIC#: ___________________________________________________________________
9.PATIENT`s CONTACT #:________________________________________________________________
10. RELATION WITH THE EMPLOYEE: ______________________________________________________
11. DATE OF ADMISSION: _______________________________________________________________
12. BED/WARD/ROOM NO: ______________________________________________________________
13. PRESENTING COMPLAINTS: ___________________________________________________________
14. PROVISIONAL DIAGNOSIS: ____________________________________________________________
15. FINAL DIAGNOSIS: __________________________________________________________________
16. ATTENDING DOCTOR’S NAME/SIGNATURES WITH STAMP:_________________________________
17. PROCEDURES TO BE UNDERTAKEN: ____________________________________________________
18. EXPECTED LENGTH OF STAY: __________________________________________________________
19. EXPECTED COST OF TREATMENT: ______________________________________________________

FOR USE BY ASKARI HEALTH:


____________________________________________________________________________________
____________________________________________________________________________________

Authorized Officer
Health Insurance Department, Askari Health: Dated: __________________

AGICO/HLT-006/00Issue Date: 30-08-2016Page 1 of 1

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