In-line with CCHI regulations, please submit all approvals ϙϟΫϭαϳϔϧΔλϧϣϖϳέρϥϋΔϘΑγϣϟ΍ΕΎϘϓ΍ϭϣϟ΍ΕΎΑϠρϊϳϣΟϝΎγέΎΑϡ΍ίΗϟϻ΍˯ΎΟέϟ΍

through Nphies Platform UCAF 2.0 ϲΣλϟ΍ϥΎϣοϟ΍αϠΟϣΕΎϣϳϠόΗϊϣΎϳηΎϣΗ

To be completed & ID verified by the reception/nurse: Insured Name: ALEXANDER LAWRENCE

Provider: GREEN CRESCENT CO.- RIYADH ID Card No: 5004593958 Sex: M Age: 50
Insurance Co. Arabian Shield Ins Co Policy Holder: SAFARI COMPANY LTD. GROUP (MED) C+
TPA: Total Care Saudi Third Party Administrators Policy No: 42MED202200021 - 2220000053_C+
Patient File No. 48397409 Visit Type: New Visit Class: C Expiry Date: 01-Jan-2023
Date of Visit: 05-Mar-2022 Approval: App8212702 Insured ID No: 2155753359 E-Code: 8982-2064-6619-301

To be completed by the Attending Physician

Admission Type: OT Emergency Case: (X) Emergency Case Level: 1 () 2 () 3 ()

BP : 120/80 Pulse : 72 Temp : 36.6 Weight : 0 Height : 0 R.R: 22 Duration of Illness: 1 Day

Chief Complaint & A CASE OF RT RENAL COLIC WITH DYSURA , FREQUANCY AND SUPRAPUBIC PAIN SINCE 2 WEEKS
Main Symptoms: U/S SHOWS right kidney show multiple stones largest 3.3cm.1.6cm,0,6 cm in pelvic regionwith no back pressure
left kidney show multiple smaller stone9.2mm at lower calyx.12mm at middla calyceal
CTUT WITHOUT CONTRAST SHOWS Right kidney staghorn stone measuring 3x4x1 cm with mild ipsilateral hydronephrosis
PLAN : THE PATIENTIS IN NEED FOR RT PCNL ( NOT AVAIALABLE IN OUR HOSPITAL )
Significant Signs:
Other Conditions: PLEASE REFFER THE PATIENT TO ANOTHER HIGHER CENTER OR HOSPITAL WITH AVAILABLE RT PCNL ( NOT AVAILABLE
IN OUR HOSPITAL ) // PLEASE FIND ATTACHED CTUT REPORT
Primary Diagnosis: N20.0 - Calculus of kidney
Other Diagnosis: N20.0 - Calculus of kidney

Benefit Type: OT Admission Date:05-Mar-2022 Discharge Date: 05-Mar-2022

Suggestive line(s) of management: Kindly enumerate the recommended investigations, and/or procedures For outpatient approvals only:

Code Description / Service Type Quantity Cost Remark

RRRR Referral to another Provider or Pharmacy OTHR 1 0.00 Referral

Providers Approval/Coding staff must review/code the recommended service(s) and allocate cost and complete the following:

Completed/Coded By: Signature: Date:

Code Medication Name Quantity Cost Remark

In Case management Form ( CMF1.0 ) included Yes ( ) No ( )

Please specify possible line of management when applicable:

I hereby certify that ALL information mentioned are correct and that the I hereby certify that ALL statements and information provided converning
medical services shown on this form were medically indicated and patient identification and the present illness or injury are TRUE.
necessary foe the management of this case.
ALEXANDER LAWRENCE
Physician Signature Stamp Date Name and relationship (if guardian):
MOHD 05-Mar-2022 Signature: Date: 05-Mar-2022
ISMAIL

For Insurance Company Use Only: Approval Validity: 14 Days

Approved / Disapproved By: Signature: Date: 05-Mar-2022

Approval Ref: App8212702

ICD10AM Dxn Code : N20.0
Request Received: 05-Mar-2022 06:11 PM
ICD10AM Dxn: Calculus of kidney
Approval Granted: 05-Mar-2022 06:23 PM
Please refer the insured with all reports to (ϰϟ΍έϳέΎϘΗϟ΍ϝϛϊϣνϳέϣϟ΍ϝϳϭΣΗϰΟέϳ): ELITE MEDICAL E-Code: 8982-2064-6619-301
& SURGICAL CENTER - RIYADH

 


 
 20,Abd. Malik Bin Ma
Post Box - 3096
Riyadh - 11471
LICENCE # 05-MAR-22 06:15 PM

PATIENT RADIOLOGY REPORT MEDISYS ID: R11021

Order No : 10257182 Request Date & Time 28/02/2022 1821

Patient No : 48397409 ALEXANDER LAWRENCE Age: 50 Y 2 M Sex: MALE

Nationality : INDIAN Marital Status:

Req Doc : 2901 MOHAMMED ISMAEL

Procedure : 110907 C.T. URINARY TRACT W/O CONTRAST
Position : S Indication : BILATERAL RENAL STONES
Diagnosis :

Report Type : Preliminary Report

The Result : CT ABDOMEN AND PELVIS WITH NO CONTRAST:

Right kidney staghorn stone measuring 3x4x1 cm with mild ipsilateral hydronephrosis. No another urinary tract stones.
No peri-nephric or peri-ureteric fat stranding. No urinary bladder gross abnormality.
Other solid abdominal organs are grossly unremarkable taking into account the limitation of the unenhanced study.
Unprepared bowel loops are within normal limits.
Small sliding hiatal hernia.
Scanned lower lungs are clear.
L5/S1 disc height reduction.
CONCLUSION:
Large right kidney staghorn stone.

Remarks :

Doctor : 201 DR. FAHD AL HEIDAN

Radiologist
Radio Diagnosis Department

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