Claim Portal Pre-Approval eForm

Admission Details

Hospital Name

Doctor Name

Admission No. / MRN And Hospital Name / Hospital Contact And Fax No

Admission Date

Expected Days Of Stay / Discharge Date

Patient Condition

Symptoms / Condition Requiring Admission

How Long Is Patient Aware Of The Condition

Patient's BP / Temp / Pulse

Date Symptom First Appeared

Date First Consulted

Any Previous Consultation / Treatment / Hospitalisation For This Symptom Or Other Disorders

Was The Patient Referred? If Yes, Please Provide Details Below

If This Condition Existed Before Symptoms Became Apparent To The Patient, Please Indicate How Long

Date	Disease / Disorder	Details of Treatment / Hospitalization	Doctor / Hospital / Clinic	Action

Can The Condition Be Managed Under The Outpatient Basis

Admitting / Provisional Diagnosis

Diagnosis Confirmed On

Advised Patient On

Case And Pathology Underlying The Present Diagnosis

Any Possibility Of Relapse

Any Other Medical/Surgical Conditions Present?

Was The Patient Pregnant At The Time Of Hospitalization? (For Female Only)

If Hospitalization Was Due To Injury, Please Describe Circumstances And Cause Of Injury

Please Indicate Date/Time Of Accident (DD/MM/YYYY) (Hrs)

AMPM

Currency

Estimated Total Costs

Medical Treatment, Investigation And Surgical Procedure To Be Performed, If Any

Is the illness / condition related to

Pregnancy / Childbirth / Infertility / Caesarean Section / MiscarriageCongenital / Hereditary DiseasesInfluence Of Drugs / AlcoholNervous / Mental / Emotional / Sleeping DisordersCosmetic Reason / Dental Care / Refractive Errors CorrectionAIDS / STD / VD / HIVSelf-Inflicted Injuries / Violation Of Laws / Strike / RiotsNone Of The Above

Supporting Documents

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New Pre-approval Case

Claimant Information

Admission Details

Patient Condition

Supporting Documents