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  • Madison Pre Authorization Form

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    chelangat
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    This document is a pre-admission authorization form that must be completed and submitted to Madison General Insurance Kenya Limited before admission for elective procedures or within 24 hours for emergency admissions. The form collects patient information like name, age, member ID, insured company, admitting hospital, diagnosis, treatment history, estimated costs, and requires a doctor's signature and stamp. On discharge, a full medical report should accompany the hospital invoice or statement submitted to Madison General Insurance for processing of claims.

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    MADISON PRE AUTHORIZATION FORM

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    This document is a pre-admission authorization form that must be completed and submitted to Madison General Insurance Kenya Limited before admission for elective procedures or within 24 hours for emergency admissions. The form collects patient information like name, age, member ID, insured company, admitting hospital, diagnosis, treatment history, estimated costs, and requires a doctor's signature and stamp. On discharge, a full medical report should accompany the hospital invoice or statement submitted to Madison General Insurance for processing of claims.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    337 views1 page

    Madison Pre Authorization Form

    Uploaded by

    chelangat
    This document is a pre-admission authorization form that must be completed and submitted to Madison General Insurance Kenya Limited before admission for elective procedures or within 24 hours for emergency admissions. The form collects patient information like name, age, member ID, insured company, admitting hospital, diagnosis, treatment history, estimated costs, and requires a doctor's signature and stamp. On discharge, a full medical report should accompany the hospital invoice or statement submitted to Madison General Insurance for processing of claims.

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    © All Rights Reserved
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    PRE-ADMISSION AUTHORIZATION

    (EMERGENCY ADMISSION/ ELECTIVE ADMISSION)


    This form MUST be completed and returned to Madison General Insurance Kenya Limited before
    admission (ELECTIVE ADMISSION) or within 24 hours (EMERGENCY ADMISSION) -
    caremanagement@madison.co.ke

    Patients Name Age Member P/No.

    Insured Company Policy No.

    Admitting Hospital Date of Admission

    Diagnosis

    When was the ailment first diagnosed?

    If pregnancy related state L.M.P If C/s state first or second

    What is the possible cause of the ailment?

    Is the ailment Congenital / malignant /chronic / recurring


    (Please indicate)

    Has an HIV Test been done? YES/NO If yes, what are the results?

    Operation required (if any)

    Clinical Summary

    Nature of treatment given &Recommendation

    Estimated cost of treatment

    Doctors Name Doctors Signature & stamp

    Date

    (A full medical report should accompany the hospital invoice /statement on discharge.)
    All communication to Madison General Insurance Kenya Limited – Healthcare Division
    Telephone 020-2864-555
    Emergency Line - 0709-922-555
    caremanagement@madison.co.ke
    medicalclaims@madison.co.ke

    HEAD OFFICE Tel 020-2864-555 Email:caremanagement@madison.co.ke


    Upper Hill Close Mobile: 0709-922-555 medicalclaims@madison.co.ke
    P.O box 46666 – 00100, Nairobi Web:www.madison.co.ke

    Madison General Insurance Kenya Limited is regulated by the Insurance Regulatory Authority

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