Sanlam General Insurance Ltd

Pre-Authorization
Approval Request
Sanlam General Insurance Limited
Gateway Place, Jakaya Kikwete Road
T
M
+254 (0)20 278 1000
+254 (0)701 701394/707 131313
Form
P.O. Box 60656-00200 Nairobi, Kenya E preauths@sanlam.co.ke
w www.sanlam.co.ke

Personal Details

Scheme Name

Hospital

Doctor

Date of admission

Tel No.

Fax No.

Patient Name

Membership No. Date of birth

Main complaints and duration

Diagnosis

Date(s) of previous treatment/consultation for this ailment

Approval requested for

In-hospital admission (elective/emergency):

Out-patient surgery (elective/emergency):

Others (Please specify and state treatment regime desired):

Signature ____________________________________ Fax No. ________________________