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    Pre Authorization Form

    Uploaded by

    Murugan Ramalingam
    This document is a pre-authorization form for UnitedHealthcare Parekh TPA India. It requests information about the employee, patient, treating physician, hospital, diagnosis, treatment plan, estimated expenses, and declarations. The form requires details on the patient's medical history, presenting complaints, diagnosis, treatment including drugs, procedures, anesthesia, and estimated length of stay. Signatures are required from the employee and treating physician to authorize sharing of medical information and confirm accuracy of the details provided.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Pre Authorization Form

    Uploaded by

    Murugan Ramalingam
    2K views1 page
    This document is a pre-authorization form for UnitedHealthcare Parekh TPA India. It requests information about the employee, patient, treating physician, hospital, diagnosis, treatment plan, estimated expenses, and declarations. The form requires details on the patient's medical history, presenting complaints, diagnosis, treatment including drugs, procedures, anesthesia, and estimated length of stay. Signatures are required from the employee and treating physician to authorize sharing of medical information and confirm accuracy of the details provided.

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    © Attribution Non-Commercial (BY-NC)

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    This document is a pre-authorization form for UnitedHealthcare Parekh TPA India. It requests information about the employee, patient, treating physician, hospital, diagnosis, treatment plan, estimated expenses, and declarations. The form requires details on the patient's medical history, presenting complaints, diagnosis, treatment including drugs, procedures, anesthesia, and estimated length of stay. Signatures are required from the employee and treating physician to authorize sharing of medical information and confirm accuracy of the details provided.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views1 page

    Pre Authorization Form

    Uploaded by

    Murugan Ramalingam
    This document is a pre-authorization form for UnitedHealthcare Parekh TPA India. It requests information about the employee, patient, treating physician, hospital, diagnosis, treatment plan, estimated expenses, and declarations. The form requires details on the patient's medical history, presenting complaints, diagnosis, treatment including drugs, procedures, anesthesia, and estimated length of stay. Signatures are required from the employee and treating physician to authorize sharing of medical information and confirm accuracy of the details provided.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    UnitedHealthcare Parekh TPA India (Pvt.

    )Ltd: Pre-Authorization Form


    Fax us on: 022 -28528222 e-mail nurseline.mumbai @uhcindia.com
    Name of Employee : Employee Ref. no:
    Company Name :
    Mobile /Res: Age /Sex:
    Email ID:
    Name of patient: Relation with Employee: Age/Sex:
    Details of treating physician and hospital
    Name of treating physician: Reg. no:
    Qualification: **Mobile & Clinic No:
    Name of hospital : Location:
    Email ID of Hospital:
    Hospital registration no: Tax approved:
    Hosp. Tel. no: Hosp. Fax no:
    Details of diagnosis ( Kindly attach Investigation Reports relevant to the diagnosis )
    Presenting complaints on Admission :

    Duration of Ailment: Previous H/O similar complaints:


    Relevant Clinical Findings:
    TPR/BP: Other vital symptoms:
    Date of first onset of symptoms: Date of first diagnosis:
    Diagnosis 1º 2º

    Mandatory in R.T.A. Mandatory in Maternity


    Under the influence of Alcohol / Drug Abuse -- Yes / No LMP- EDD- G___P___A___L___
    MLC / FIR Copy YES / NO ( Kindly Fax the copy) Type of Delivery: Normal / LSCS -
    Details of Accident: Indication for LSCS:
    In case of MTP: Voluntary / Medical (USG Report Mandatory)
    Date of Admission: Expected length of stay Hospitalization Less than 24
    hrs. No/ Yes
    Kindly specify the Names of Medicines:
    Drugs Inject. (√) Oral (√)
    Drugs Inject. (√) Oral (√) Tick where Applicable
    Antibiotics
    Anti-inflam. drugs Steroids IV transfusions
    Neuro-musc. drugs Chemotherapy Radiotherapy
    Cardiac drugs Sedatives Blood Transfusion
    Respiratory drugs Diuretics Continuous traction
    Others GI drugs
    Names of Investigations supporting to Diagnosis:

    **Surgical treatment/ Procedure: **Anaesthesia:

    Estimate Expenses No Of Attached Documents : Past History


    Class of Room ________________________ **History of : Since
    Room Rate / Day *All the above mentioned fields Alcohol/Drug Abuse – Yes / No
    Investigation (Attach Breakup) are required to be filled in Block Tobacco Consumption – Yes / No
    Consumables/Pharmacy (Attach Breakup) letters.*Avoid over writing and Disease Ailment
    Dr. Visit Charge abbreviations.*Strike out Dyslipidaemia
    Surgeon Charge whichever is not Diabetes
    Anesthetist Charge applicable*Please provide Hypertension
    O.T. Charge Discharge summary & Final bill History of surgery
    All inclusive Package Charges if applicable 3 hours prior to discharge of the History of similar Compliant
    Total Expenses patient**Mandatory fields History of related Ailment
    DECLARATION

    ƒ I hereby declare that the information provided in the form is true to the best of my knowledge, and authorize UnitedHealthcare India to seek any further information from
    the treating doctor / hospital if needed
    ƒ I am aware that the liability of UnitedHealthcare for treatment is limited to facilitating credit and refusal of credit does not amount to rejection of claim
    ƒ I undertake that if cashless facility is availed, all original documents, including the discharge summary and investigation reports shall be handed over to the hospital at the time
    of discharge along with the signed claim form. I am aware that without these documents the claim cannot be processed and I am liable for the same
    ƒ I am aware of my health insurance cover and if the hospital expenses exceed the amount, I shall be liable to pay the remainder of the amount at the time of discharge
    ƒ I undertake p to pay all non-medical expenses
    y incurred
    p y in the hospital at the time of discharge
    y p y, p y
    have kindly extended the hospital credit facility

    Date : ___________________ Employee Signature:_____________________________


    As a treating phusician, I hereby declare that the medical information declared in the form is accurate to the best of my knowledge, if the same is changed/Altered, UHCI is not
    liable to pay the bill to the Hospital for the respective case.

    Date : ___________________ Hospital Stamp (Mandatory) Treating Physician Signature:_____________________________

    Note -: 1. PreAuthorization may cause Delay in processing, if any detail in the form is found Incomplete or Inaccurate.
    2. Kindly fax all the relevant documents like Investigation / MLC / FIR Reports where ever applicable.

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