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PREAUTHORIZATIONINFORMATIONFORM

MandatoryforNonEmergencyHospitalization

P a k Q a t a r F a m i l y T a k a f u l L i m i t e d
PakQatarsFaxNo.:(021)4386451
ForBenefit&Eligibilityinquiry:(021)438035761
FaxDate:
; TobecompletedbythecoveredIndividualMemberonly. Attention:
Part
; Donotleaveanyblank,unansweredquestions,datesorsignatures,whereverapplicable.



A PatientsTakafulCertificateNumber: PatientsSex: Male Female

PatientsName: Age:

DateofBirth: CNIC Number:

ResidenceAddress: Mobile:
SchemeNumber: Participant(Employer)Name:

EmployeeName: Relationshipwithpatient:

; TobecompletedbytheTreatingPhysicianonly.
Part
; Donotleaveanyblank,unansweredquestions,datesorsignatures,whereverapplicable.

B NameofTreatingPhysician:
HospitalName(wheretreatmentrequired):

Symptoms:

Onwhatdatedidthesymptomsfirstoccur:

PrincipalDiagnosis:

AssociatedDiagnosis:


Hasthepatientpreviouslyconsultedanydoctorfortheabovementionedmedicalcondition?Yes No
IfYes,foreachdoctorandhospitalconsulted,statenameandaddress,treatmentprovided.


NameofDoctor/Hospital DateofConsultation ReasonforConsultation Treatment/Results






Procedure/Operation/Treatmentadvised:


VerificationbyTreatingPhysician:I/Weherebycertifythatallanswerstoquestions

appearingabovearetrueandcompletetothebestofmy/ourknowledgeandbelief.


DateofStatement: Signatureofphysician


ExpectedDateofAdmission: DECLARATION&AUTHORIZATION
Part
Iherebycertifythatallanswerstoquestionsappearingonthisformand


C ExpectedDurationofHospitalization: documentssubmittedwiththisformaretrueandcompletetothebestof
myknowledgeandbelief.
I, the above claimant, hereby authorize any doctor , hospital,, clinic, or
medical service provider, takaful/insurance company, or any other
ExpectedcostofHospitalization institution, or any person, who has any information or record about me
and/or any of my dependents to provide PakQatar Family Takaful
Expectedbreakupofitems ExpectedAmount Limited with the complete information including copies of their records
(inPakRupees) with reference to any sickness, accident, disability, any treatment,
examination, medical investigation, advice of healthcare provider,.
Room&Board Photocopyofthisauthorizationshallbevalidastheoriginal.

PhysicianVisitFee

CostofProcedure/Operation

SurgeonFee
SignatureofclaimantIndividualMember
AnesthesiaFee Employeewillcompleteandsignthisformonbehalfofminorchildren

Laboratory

Medicines
DateofStatement:
Others

Ifyouhaveanyquestionsregardingpreauthorizations,contactourCustomerBenefitServicesDepartment:at(021)438035761,4386452.

Themedicalinformationcontainedinthisfacsimilemessageand/ordocumenttransmittedisconfidentialandintendedsolelyfortheuseoftheindividualorentity
namedabove.Ifthereaderofthismessageisnottheintendedrecipient,youareherebynotifiedthatanyexamination,use,dissemination,distributionorcopying
ofthiscommunicationisstrictlyprohibited.Ifyouhavereceivedthiscommunicationinerror,pleasenotifyusimmediatelybytelephone,andreturntheoriginal
messagetousattheaddressabove.
RefNo.:GH/CL/2008/00040/1