Inpatient Pre-Authorization Request Form

Please fill all sections

For any queries please contact our 24 hour Medical Services helpline at:
For Inpatient queries: Tel: 020 2895300 | 0703 063300 | 0730633300
For Outpatient / Emergency queries: Tel: 020 2895333 | 0703 063333 | 0730 633333
Email: medicalservices@aar.co.ke

A: PATIENT INFORMATION (to be completed by the member / patient / guardian/ next of kin only)

Name:

Date of Birth: Membership No. Company/Employer:

Telephone No. Email:

Name of next of kin: Telephone number:

I understand that:
• The Hospitalization will be covered as per the Terms and Conditions of the latest policy document & declaration.
• AAR Insurance will confirm payment of hospital bills (or NOT) based on a comprehensive medical report(s) from treating doctor(s).
• I am liable for any costs which AAR Insurance will not undertake to cover. I will take necessary steps to ensure that I am able meet these costs.

Member / Guardian Signature: Date:

B: CLINICAL INFORMATION (to be completed by attending Medical Practitioner or Consultant)

Complaints including date of onset:

Physical findings:

Laboratory & Radiology findings:

Diagnosis:

Management plan: (Including estimated costs for procedures):

Admission Date: Hospital / Facility: Stamp

Attending Practitioner: Speciality:

Please attach a detailed invoice & discharge summary and send to the address below within 30 days from date of discharge.
Claims Department/Manager, AAR Insurance Kenya Ltd. Real Towers, Hospital Road, Upper-Hill, Ground Floor
P.O. Box 41766 - 00100,GPO Nairobi, Kenya