Room

6,000

5,000

4,000

Room

3,000

2,000

1,000

0
 Corporate Business Division
‫کارپوریٹ بزنس ڈویژن‬

PRE-AUTHORIZATION REQUEST
INPATIENT
Emergency Admission Regular Admission Day Care Admission Special Investigations

MR Number : 22-07-77-17 Company: PQFT

Pt. Name : Tanveer Ahmed Employer: COMSATS
Age/ Gender: Male Policy No:
CNICNo: 1420230219307 Plan / Class / Group: Room 5,000
Relation: Self
of Insured: Tanveer Ahmed Date of Admission / Procedure: 7-Sep-22
Insurance ID: Cert: FT201912000501B-380 Bed / Room No. (If Admitted) :
Employee ID: Estimated Length of Stay: 1-2 days
Contact No: 0335-5159120 Estimated Treatment Cost: PKR 250,000/-

Treating Physician/s: Dr. M Amin

Presenting Complaints / Symptoms: As attached

Diagnosis : (Provisional or Initial) As Attached

Duration of Illness ( Since When ? ) : As Attached

Is this a Congenital Disorder / Disease ? : As Attached

Treatment Plan / Pathway : As Attached

Procedure/s Planned (If any): Code Procedure Description

Surgical

Interventional

Diagnostic

Others Remarks:

Does the Patient need a Contact Isloation?

APPROVED With Limit of : Amout in PKR: Days:

Received @ Date: Time:

Authorized @ Date: Time:
Remarks:
REGRETTED