TOP UP PRE-AUTHORISATION FORM

Private and Confidential / Sulit dan Persendirian

TOP UP REQUEST FORM - 1st Page

To be completed by the Attending Physician along with the following documents:
a. A copy of interim bill as of to date
b. A copy of the Undertaking Letter issued by Prudential Assurance Malaysia Berhad
c. A copy of Medical Report Part I or Part II if completed by the Attending Doctor

The above matter refers.

Medical fees as of to date have exceeded the Undertaking Letter amount or length of stay that has issued for the above
mentioned. Please find below medical progress information for your perusal.

1 a. Patient Name: b. NRIC:

2 a. Policy No.: 3 a. Date:

b. Claims No: b. Current Length of Stay:

4 a. Current Diagnosis / Additional Diagnosis (if any).

ICD Code:

b. Current Treatment / Surgical Procedure.

Procedure/PHA code:

5. Current Medical Condition / Additional Investigation and Lab Test:

Please supply copy of all the investigation and lab report/result.

TOP UP PRE-AUTHORISATION FORM
Private and Confidential / Sulit dan Persendirian

TOP UP REQUEST FORM – 2ND Page

To be completed by the Attending Physician along with the following documents:
a. A copy of interim bill as of to date
b. A copy of the Undertaking Letter issued by Prudential Assurance Malaysia Berhad
c. A copy of Medical Report Part I or Part II if completed by the Attending Doctor

6. Any Medical or Surgical Complication

7. Estimated

(i) Length of Stay: ________________ day(s)

(ii) Total estimated cost of medical expenses: RM ____________________

8. Any additional information which you think relevant for us to assess this Top Up request:

9. I hereby certify that I have personally examined and treated the Assured for his/her injuries /Illness describes above
and that the facts as stated above represent my medical opinion of his/her condition

____________________ __________________________________________________ _________________

Date Name & Signature of Attending Doctor Hospital Stamp