Treatment Guarantee Form

Failure to complete this form fully will delay your insurance company’s ability to guarantee your treatment as they may
have to revert to you or the medical provider for further information. The patient’s policy must be in force at the time of
treatment. Please be advised that guarantee of payment is subject to the terms and conditions of the insurance policy
and also subject to the assessment of all relevant documentation received, or yet to be received, by your insurance
company in respect of this medical condition.

Please be aware that it may be necessary to request further information before completing the Treatment Guarantee
process. Thank you.

Section 1 must be fully completed by (or on behalf of) the patient

Section 2 must be fully completed by the doctor.

1. PATIENT DETAILS - to be fully completed by (or on behalf of) the patient

Policy Number:
First name: Middle initials:
Last name:
Date of birth: (DDMMYYYY)

Contact person please specify who should be contacted regarding this Treatment Guarantee request

Name:
Relationship to patient (e.g. self, spouse/partner, parent):
Telephone (incl. country and area codes):
Mobile telephone (incl. country and network codes):
Email:

2. TREATMENT DETAILS - to be fully completed by the medical provider

If additional treatment is required, your insurance company must be notified.

Medical Condition

On what date would the first onset of symptoms have been apparent to the patient?
(DDMMYYYY)
Date of first attendance for this condition: (DDMMYYYY)
Previous related treatment history:

Description of the signs and symptoms:

Diagnosis (if unknown, please state provisional diagnosis):

ICD9/10 DSM IV DRG

Treatment Plan

Planned procedure/treatment details:

Planned date of admission: (DDMMYYYY)

Expected date of discharge: (DDMMYYYY)

Please provide the following details for maternity cases:

Date pregnancy confirmed by doctor: (DDMMYYYY)

Expected or actual date of delivery: (DDMMYYYY)
Delivery method:
Is birth of a single baby expected? Yes  No 
If No, is the pregnancy a result of medically assisted reproduction other than artificial insemination? Yes  No 

Estimate Costs

Estimated hospital charges (incl. currency):

Estimated physician charges (incl. currency):

Medical provider details

Hospital/facility name:
Address (incl. country):

Email (mandatory):
Telephone (incl. country and area codes):
Fax (incl. country and area codes):

Attending/admitting physician
Name:
Email:
Telephone (incl. country and area codes):

Please sign, date and authenticate with an official stamp.

I confirm that all the details given in this form are, to the best of my
Official stamp of medical provider
knowledge, true, accurate and complete.

Doctor’s signature:
Date: (DDMMYYYY)