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: MESHAL QAED AHMED QASEM
Insurance Company Name: Tawuniya ID. Card No: 002077829329001 National ID: 2077829329
TPA Company Name: N/A Sex: Male Age: 31 Years
Patient File Number: 24940 Policy Holder: DIGITAL SOLUTIONS PROVIDER CO
Dept: Urology Policy No: 27056119
Single ( ) Married ( ) Member Since: Member Type: PRINCIPAL
Plan Type ( ) Expiry Date: Class: 5
Date of visit: 07-07-2023 05:17 Approval: Approval Type: INPATIENT
New visit ( ) Follow Up ( ✓ ) Refill ( ) Walk In ( ) Referral ( ) Approval Reference Number: 60247630
Approval Date/Time: 07-07-2023 05:17 Approval Status: Approved
Approval Validity: 30 Days Message:

To be Completed by the Attending PHYSICIAN: Please tick ( ✓ )

Inpatient ( ✓ ) Outpatient ( ) Emergency Case ( ) | Emergency Care Level: 1( ) 2( ) 3( ) 4( ) 5( )
Physician Name [ID]: DR.OSAMA ABDOON [0]
BP: Pulse: Temp: Weight: Height: R.R: Duration of Illness: 0 Days
Chief Complaints and Main Symptoms: 31 YEARS OLD MALE , MEDICALLY FREE, COMPLAIN OF SCROTAL PAIN FOR 4 YEARS , INCREASE WITH PROLONG STANDING ,
SCROTAL SWELLING ,,O.E GRADE III BILATERAL VARICOCELE, US NORMAL SIZE TESTIS AND EPIDIDYMIS , 3.3 AND 3.5 RIHGT AND LEFT DIAMETER OF PAMPINIFORM
PLUXS ,, PATIENT COUNCILLING DONE , AS THE PATIENT HE COMPLAIN OF PAIN WITH GRADE III (THREE ) COMPLICATION EXPLANIED AND HE ACCEPTED
Siginficant Signs:
Possible Line of Treatment:
Other Conditions:
Diagnosis:
Principal Code: I86.1 2nd Code: 3rd Code: 4th Code:

Please tick ( ✓ ) where appropriate:

Chronic ( ) Congenital ( ) RTA ( ) Work Related ( ) Vaccination ( )
Check-up ( ) Psychiatric ( ) Infertility ( ) Pregnancy ( ) Indicate LMP:
Suggestive line(s) of management: Kindly, enumerate the recommended investigations, and/or procedures For outpatient approvals only:

Code Service Type Req. Qty Req. Cost App. Qty App. Cost
URO-0015 Laparoscopic Varicocele [ URO-0015 ] N_A 2 13090 2 13090
Providers Approval/Coding Staff must review/code the recommended service(s) and allocate cost and complete the following:
Completed/Coded By. . . . . . . . . . . . . . . . Signature. . . . . . . . . . . . . . . . Date . . . . . . ./ . . . . . . . ./ . . . . . . .

Medication Name (Generic Name) Type Req. Qty Req. Cost App. Qty App. Cost

In case Management Form (CMF1.0) includedYes ( ) No ( )

Please specify possible line of management when applicable: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Estimated Length of stay: 1 days Expected date of admission:25-06-2023 19:58
Approved Length of stay: 1 days Estimated Cost:(SAR)13090 Total Approved Cost:(SAR)13090

Provider Comments:
[ Date and Time: 04-07-2023 18:22 ] 31 YEARS OLD MALE , MEDICALLY FREE, COMPLAIN OF SCROTAL PAIN FOR 4 YEARS , INCREASE WITH PROLONG STANDING ,
SCROTAL SWELLING, O.E GRADE III BILATERAL VARICOCELE, --------------SEMEN ANALYSIS: COUNT 78 MILLION , TOTAL MOTILITY 63, PROGRESSIVE MOTILITY
30ULTRASOUND 22/6/2023 NORMAL SIZE TESTIS AND EPIDIDYMIS , 3.3 AND 3.5 RIHGT AND LEFT DIAMETER OF PAMPINIFORM PLUXS BY COLOR DOPLLER -----------
------------- PATIENT COUNCILLING DONE , AS THE PATIENT HE COMPLAIN OF PAIN WITH GRADE III (THREE ) VARICOCELE , WITH NEARLY NORMAL SEMEN ANALYSIS
AS THE MAIN CONCERN OF PATINET FOR THE TIME BEING IS SCROTAL PAIN SO WE OFFER FOR HIM BILATERAL LAPAROSCOPIC VARICOCELECTOMY , COMPLICATION
EXPLANIED AND HE ACCEPTED.
[ Date and Time: 04-07-2023 11:16 ] PLZ CHECK THE ATTACHMENT
[ Date and Time: 04-07-2023 11:16 ] Attachment URL: https://waseeler.waseel.com/waseeler/web/xhtml/DMS/ViewAttachment.jsf?id=13625882
[ Date and Time: 26-06-2023 18:36 ] 31 YEARS OLD MALE , MEDICALLY FREE, COMPLAIN OF SCROTAL PAIN FOR 4 YEARS , INCREASE WITH PROLONG STANDING ,
SCROTAL SWELLING, O.E GRADE III BILATERAL VARICOCELE...............................................PATIENT COUNCILLING DONE , AS THE PATIENT HE COMPLAIN OF PAIN WITH
 GRADE III (THREE ) WITH NEARLY NORMAL SEMEN ANALYSIS, AS THE MAIN CONCERN OF PATINET FOR THE TIME BEING IS SCROTAL PAIN SO WE OFFER FOR HIM
BILATERAL LAPAROSCOPIC VARICOCELECTOMY , COMPLICATION EXPLANIED AND HE ACCEPTED................................................ SEMEN ANALYSIS: COUNT 78 MILLION ,
TOTAL MOTILITY 63, PROGRESSIVE MOTILITY 30ULTRASOUND 22/6/2023 NORMAL SIZE TESTIS AND EPIDIDYMIS , 3.3 AND 3.5 RIHGT AND LEFT DIAMETER OF
PAMPINIFORM PLUXS BY COLOR DOPLLER.
Payer Comments:
[ Date and Time: 07-07-2023 05:17 ] APPROVED SUBJECT TO POLICY,CONTRACTS,CONDITIONS,LIMITS,EXCLUSIONS AND AGREED PRICES/PACKAGES
[ Date and Time: 04-07-2023 11:23 ] Disapproved_H3 - The submitted medical data is not justifying the requested services at this stage of disease.
[ Date and Time: 26-06-2023 18:50 ] Furhter Deatils Required_H2 - Please update results of testicular ultrasound and semen analysis and if related to infertility.
[ Date and Time: 25-06-2023 20:19 ] Furhter Deatils Required_H1 - Please update results of testicular ultrasound and semen analysis and if related to infertility.
Comment:

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: 60247630 Approval validity: 30 Days
Comments (include approved days/services if different from the requested) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Approved/Disapproved By . . . . . . . . . . Signature . . . . . . . . . . . . . . Date: . . . / . . ./ . . .

(*) this is applicable only in case of manual UCAF