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    اقبال

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    hamadamedo400

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    © All Rights Reserved
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    اقبال

    Uploaded by

    hamadamedo400
    3 views1 page

    Copyright

    © © All Rights Reserved

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    Copyright:

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    3 views1 page

    اقبال

    Uploaded by

    hamadamedo400

    Copyright:

    © All Rights Reserved
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    UCAF 2.

    0
    To be completed & ID verified by the reception/nurse: Print/Fill in clear letters or Emboss Card:
    Provider Name: MEDICAL PROGRESS TOWER COMPLEX Insured Name: IKBAL HOSSAIN ALI MIA
    Insurance Company Name: The Mediterranean and Gulf Cooperative Insurance and ID. Card No.: 5747250 Sex: MALE Age: 33 Y
    Reinsurance Company (MedGulf) Policy Holder: Policy No.: 17027988
    TPA Company Name: Expiry Date: 2025-06-19 Class:
    Patient File Number: Dept: professional - 08.00 - Internal Medicine Specialty Approval: 2024/4198291
    Single ( ) Married ( ) Plan Type EHCPOL Approval Status: partial
    Date of visit: 23 / 07 / 2024
    New visit ( ) Follow Up ( ) Refill ( ) Walk In ( ) Referral ( )
    Referral: Yes Referral PreAuth Provider: AL NAHDI MEDICAL COMPANY -PHARMACY -
    JEDDAH

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


    Inpatient ( ) Outpatient ( ) Emergency Case ( ) Emergency Care Level: 1 ( ) 2 ( ) 3 ( )
    BP: / Pulse: bpm Temp: °C Weight: kg Height: cm R.R: Duration of Illness: (Days)
    Chief Complaints and Main Symptoms: (K58)

    Significant Signs:
    Other Conditions:
    Diagnosis: (K58) - (Irritable bowel syndrome), (R11) - (Nausea and vomiting)
    Principal Code: K58 2nd Code: R11 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 Non Standard Description/Service Type Total Cost approved approved Status
    Code Quantity Quantity Cost
    06285128000307 79-368-04 DOMPY 10MG TABLET medication- 1 13.85 1 0.01 partial
    codes
    08002660016317 21-137-00 DUSPATALIN 200MG PROLONGED RELEASE medication- 1 48.15 0 0 partial
    CAPS codes
    24-1022-2008 24-1022-2008 NEOCARBON (ACTIVATED CHARCOAL WITH medication- 1 12.95 0 0 partial
    ANISE AND MINT ESSENCE) codes

    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 Quantity

    In Case management Form (CMF 1.0) included Yes ( ) No ( )


    Please specify possible line of management when applicable:
    Estimated Length of stay: days Expected date of admission:

    I hereby certify that ALL information mentioned are correct and that the medical I hereby certify that ALL statements and information provided
    services shown on this form were medically indicated and necessary for the concerning patient identification and the present illness or injury are
    management of this case. TRUE.
    Physician Signature Stamp Date Name (and relationship (if guardian)):
    Kyrollos Atta Signature (*): Date:

    For Insurance Company Use Only: Approved ( ) Not Approved ( ) Approval No.: Approval validity: 23/07/2024 - 22/08/2024 -2592000000 Days
    Comments (include approved days/services if different from the requested): 1 - - Please refer the patient to whites/ kunooz \ Al Nahdi / AL DWAA /
    UNITED /lemon , kindly provide Invoices . original stamped prescription
    and waseel print to the patient )

    Approved/Disapproved By: Signature: Date:

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

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