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MandatoryforNonEmergencyHospitalization
P a k Q a t a r F a m i l y T a k a f u l L i m i t e d
PakQatarsFaxNo.:(021)4386451
ForBenefit&Eligibilityinquiry:(021)438035761
FaxDate:
; TobecompletedbythecoveredIndividualMemberonly. Attention:
Part
; Donotleaveanyblank,unansweredquestions,datesorsignatures,whereverapplicable.
A PatientsTakafulCertificateNumber: PatientsSex: Male Female
PatientsName: Age:
DateofBirth: CNIC Number:
ResidenceAddress: Mobile:
SchemeNumber: Participant(Employer)Name:
EmployeeName: Relationshipwithpatient:
; TobecompletedbytheTreatingPhysicianonly.
Part
; Donotleaveanyblank,unansweredquestions,datesorsignatures,whereverapplicable.
B NameofTreatingPhysician:
HospitalName(wheretreatmentrequired):
Symptoms:
Onwhatdatedidthesymptomsfirstoccur:
PrincipalDiagnosis:
AssociatedDiagnosis:
Hasthepatientpreviouslyconsultedanydoctorfortheabovementionedmedicalcondition?Yes No
IfYes,foreachdoctorandhospitalconsulted,statenameandaddress,treatmentprovided.
NameofDoctor/Hospital DateofConsultation ReasonforConsultation Treatment/Results
Procedure/Operation/Treatmentadvised:
VerificationbyTreatingPhysician:I/Weherebycertifythatallanswerstoquestions
appearingabovearetrueandcompletetothebestofmy/ourknowledgeandbelief.
DateofStatement: Signatureofphysician
ExpectedDateofAdmission: DECLARATION&AUTHORIZATION
Part
Iherebycertifythatallanswerstoquestionsappearingonthisformand
C ExpectedDurationofHospitalization: documentssubmittedwiththisformaretrueandcompletetothebestof
myknowledgeandbelief.
I, the above claimant, hereby authorize any doctor , hospital,, clinic, or
medical service provider, takaful/insurance company, or any other
ExpectedcostofHospitalization institution, or any person, who has any information or record about me
and/or any of my dependents to provide PakQatar Family Takaful
Expectedbreakupofitems ExpectedAmount Limited with the complete information including copies of their records
(inPakRupees) with reference to any sickness, accident, disability, any treatment,
examination, medical investigation, advice of healthcare provider,.
Room&Board Photocopyofthisauthorizationshallbevalidastheoriginal.
PhysicianVisitFee
CostofProcedure/Operation
SurgeonFee
SignatureofclaimantIndividualMember
AnesthesiaFee Employeewillcompleteandsignthisformonbehalfofminorchildren
Laboratory
Medicines
DateofStatement:
Others
Ifyouhaveanyquestionsregardingpreauthorizations,contactourCustomerBenefitServicesDepartment:at(021)438035761,4386452.
Themedicalinformationcontainedinthisfacsimilemessageand/ordocumenttransmittedisconfidentialandintendedsolelyfortheuseoftheindividualorentity
namedabove.Ifthereaderofthismessageisnottheintendedrecipient,youareherebynotifiedthatanyexamination,use,dissemination,distributionorcopying
ofthiscommunicationisstrictlyprohibited.Ifyouhavereceivedthiscommunicationinerror,pleasenotifyusimmediatelybytelephone,andreturntheoriginal
messagetousattheaddressabove.
RefNo.:GH/CL/2008/00040/1