Professional Documents
Culture Documents
UCAF 2.0
To be completed and ID verified by the reception/nurse: Print/Fill in clear letters or Emboss Card:
Provider Name: Dr. AWWAD ALBISHRI HOSPITAL - MAKKAH [ DAAH ] Insured Name: Hassan Talal Abdullah Zagzoog
Insurance Company Name: Tawuniya National ID / Iqama No: 1046328611
ID. Card No: 001046328611001
TPA Company Name:
Sex: Male DOB: 22-03-
Patient File Number: Dept: Emergency
1973
Single ( ) Married ( ) PlanType ( Tailored Product )
Date of visit: 13-12-2023 01:30 Policy Holder: SAUDI AIRLINES GROUP
Policy No: 202320241 Expiry Date: 05-03-2024
New visit ( ) Follow Up ( ) Refill ( ) Walk In ( ) Referral ( )
Class: A-R Approval:
Status: ELIGIBLE
Eligibility Reference Number: 185195018
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12/13/23, 1:33 AM Printable Version - Eligibility Reference No: 185195018
Providers Approval/Coding Staff must review/code the recommended service(s) and allocate cost and complete the following:
Completed/Coded By. . . . . . . . . . . . . . . . Signature. . . . . . . . . . . . . . . . Date . . . . . . ./ . . . . . . . ./ . . . . . . .
I hereby certify that ALL information mentioned are correct and that the medical I hereby certify that ALL statements and information provided concerning patient
services shown on this form were medically indicated and necessary for the identification and the present illness or injury are TRUE.
management of this case. Name (and relationship if guardian): . . . . . . . . . . . . . . . .
Physician Signature Stamp Date Signature(*). . . . . . . Date. . . . . . . ./ . . . . . . . ./ . . . . . . .
◯
........ ........ . . . . . . ./ . . . . . . ./ . . . . . . .
For Insurance Comapny Use Only: Approved ( ) Not Approved ( ) Approval No: . . . . . . . . . . . . . . . . . Approval validity: . . . . . . . . . . . . . .Days
Comments (include approved days/services if different from the requested) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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