12/10/23, 4:46 PM Printable Version - Eligibility Reference No: 184706104

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: Amal Saud Saad Alghamdi
Insurance Company Name: Tawuniya National ID / Iqama No: 1013995749
ID. Card No: 001013995749001
TPA Company Name:
Sex: Female DOB: 04-02-
Patient File Number: Dept: ENT
1974
Single ( ) Married ( ) PlanType ( Gold B )
Date of visit: 10-12-2023 16:49 Policy Holder: BASAMAT CO
Policy No: 30962228 Expiry Date: 26-07-2024
New visit ( ) Follow Up ( ) Refill ( ) Walk In ( ) Referral ( )
Class: GL/B Approval:
Status: ELIGIBLE
Eligibility Reference Number: 184706104

Consult. Fee Max Limit:Covered Deductible:20 % To be Collected: Yes

Approval Limit: Deductible Desc:Max 100 SAR Per Claim

true
Special Member Info:

Special coverage info:

Consult. Fee Max Limit: Deductible:

Approval Limit: Deductible Desc:

Special Member Info:

Special coverage info:

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

Inpatient ( ) Outpatient ( ) Emergency Case ( ) | Emergency Care Level: 1( ) 2( ) 3( )
BP:. . . . . . / . . . . . Pulse:. . . . . . .bpm Temp:. . . . . . . . ℃ Weight:. . . . . . .Kg Height:. . . . . . .cm R.R:. . . . . . . . . Duration of Illness:. . . . . . . .(Days)
Chief Complaints and Main Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...........................................................................................................................................
Siginficant Signs: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other Conditions: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diagnosis: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Principal Code: . . . . . . . . . . . . . 2nd Code: . . . . . . . . . . . . . 3rd Code: . . . . . . . . . . . . . 4th Code: . . . . . . . . . . . . .

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12/10/23, 4:46 PM Printable Version - Eligibility Reference No: 184706104

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 Description/Service Type Quantity Cost

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 (CMF1.0) includedYes ( ) 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 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: . . . . . . . . . . . . . . . . . Approval validity: . . . . . . . . . . . . . .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

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