Out-Patient Services Authorization Letter

‫ﺧﻄﺎﺏ ﻣﻮﺍﻓﻘﺔ ﺧﺪﻣﺎﺕ ﻋﻴﺎﺩﺓ ﺧﺎﺭﺟﻴﺔ‬

Dear / L43 Alfa Laboratories, ‫ ﻣﻌﺎﻣﻞ ﺃﻟﻔﺎ‬/ ‫ﺍﻟﺴﺎﺩﺓ‬

Kindly assist MedNet card holder to get your best services, with our sincere ‫ﺑﺮﺟﺎﺀ ﺗﻘﺪﻳﻢ ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﻜﺎﻣﻠﺔ ﻟﺤﺎﻣﻞ ﺑﻄﺎﻗﺔ ﻣﻴﺪﻧﺖ ﻭﻣﺴﺎﻋﺪﺗﻪ ﻓﻰ ﺍﻟﺤﺼﻮﻝ ﻋﻠﻰ ﺃﻓﻀﻞ‬
wishes for a quick recovery and good health. .‫ ﻣﻊ ﺧﺎﻟﺺ ﺗﻤﻨﻴﺎﺗﻨﺎ ﻟﻪ ﺑﺪﻭﺍﻡ ﺍﻟﺼﺤﺔ ﻭﺍﻟﻌﺎﻓﻴﺔ‬،‫ﺧﺪﻣﺎﺗﻜﻢ‬
Thank you for your kind cooperation ‫ﻭﺷﻜﺮﺍ ﻟﺤﺴﻦ ﺗﻌﺎﻭﻧﻜﻢ‬

Online Rejected Authorization

‫ﺧﺪﻣﺎﺕ ﻏﻴﺮ ﻣﻐﻄﺎﺓ‬

Authorization Date: 25/03/2023 Authorization No.: 6861561 Expiry Date: 04/04/2023

‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻮﺍﻓﻘﺔ‬ ‫ﺭﻗﻢ ﺍﻟﻤﻮﺍﻓﻘﺔ‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻮﺍﻓﻘﺔ‬
Beneficiary Name: ‫ﺍﺳﻢ ﺍﻟﻤﺴﺘﻔﻴﺪ‬ Card Number: 565415
Egyptian Takaful Insurance Company-EGTAK
‫ﺑﺮﺍﺀ ﻣﺤﻤﺪ ﺣﺼﺎﻓﻰ ﻓﺘﺤﻰ ﻣﺤﻤﻮﺩ‬ ‫ﺭﻗﻢ ﺍﻟﺒﻄﺎﻗﺔ ﺍﻟﻄﺒﻴﺔ‬
Diagnosis: Diagnosis Code: 789.0
ABDOMINAL PAIN
‫ﺍﻟﺘﺸﺨﻴﺺ‬ ‫ﻛﻮﺩ ﺍﻟﺘﺸﺨﻴﺺ‬

Rejected Services: :‫ﺍﻟﺨﺪﻣﺎﺕ ﺍﻟﻐﻴﺮ ﻣﻐﻄﺎﺓ‬

The below services will not be paid due to the following reasons ‫ﻟﻦ ﻳﺘﻢ ﺍﻟﻤﺤﺎﺳﺒﺔ ﻋﻠﻰ ﺍﻟﺨﺪﻣﺎﺕ ﺍﻟﺘﺎﻟﻴﺔ ﺑﻨﺎﺀ ﻋﻠﻰ ﺍﻷﺳﺒﺎﺏ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﺩﻧﺎﻩ‬

Service Description Rejected Service Rejection Reason

Quantity
‫ﺍﺳﻢ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﻜﻤﻴﺔ ﺍﻟﻤﺮﻓﻮﺿﺔ‬ ‫ﺳﺒﺐ ﺭﻓﺾ ﺍﻟﺨﺪﻣﺔ‬

Familial Mediterranean Fever Gene 0.000

Notes: :‫ﻣﻼﺣﻈﺎﺕ‬
‫ﺍﻟﺘﺸﺨﻴﺺ ﻏﻴﺮ ﻣﻐﻄﻰ‬
‫ﺗﻢ ﺍﺭﻓﺎﻕ ﺍﻟﻨﻤﻮﺫﺝ ﻻﻥ ﺍﻟﺘﺸﺨﻴﺺ ﻏﻴﺮ ﻭﺍﺿﺢ‬

Authorizing Doctor Code: Stamp & signature

Provider User Name: elraml
Department:
Originally Created In: 25/03/2023

Hotline Number: 202 24636100 Fax Number: +202 24636101 Page No(s): 1/1
E-mail: approvals@mednet.com.eg

MedNet Egypt L.L.C.