PreAuthorization

You are responsible for completing this form and are solely responsible for its accuracy and completeness.
All questions must be answered in full, and all dates must be included where noted otherwise the pre-authorization form maybe returned to you resulting in a delay in processing and possibly a delay in the treatment.
Type or print CLEARLY in blue or black.

Section A: Patient Information

Name (Full Name):*

Membership ID Number:*

Section B: Medical Information

1. Please share the symptoms that the patient is suffering from or if available the diagnosis? *

2. When the symptoms first began or when the injury/accident occurred (DD/MM/YYYY):*

3. Please tell us what treatments, investigations or procedures you are seeking pre-authorizations for? *

4. If you are seeking approval for a day case or inpatient medical procedure please tell us your planned admission and discharge dates DD/MM/YY

Planned Admission Date:*

Planned Discharge Date:*

* 5. If available, please tell us the estimated costs:

Section C: Hospital and Physician Information

Hospital/facility name:*

Tax ID number (U.S. hospitals only):

Physician / Provider name:*

Tax ID number (U.S. doctors only):

Street Address:*

City:*

Post Code:*

Country:*

Telephone:*

Email:*

Section D: Authorization by Patient

Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.

The above answers are true and correct to the best of my knowledge. I authorize any physician, medical institution, pharmacy, insurance company, employer, labor union, or association to release information to SureGo Administrative Services LLC as required to properly pay all benefits, if any due to me, my spouse, or any other dependents. photocopy of this authorization shall be considered effective and valid as the original.

If the approved cost of treatment or maximum stay are to be exceeded, further approval must be sought before discharge. All unapproved charges are the responsibility of the patient and must be recovered by the hospital/clinic from the patients prior to discharge.

Name:*

Date: (DD/MM/YY)*

Signature:*

By typing my name on this form, I am signing electronically, and this electronic signature is the legal equivalent of my manual, handwritten signature.

The policyholder and the insured person(s) explicitly agree to this agreement.

I explicitly agree to this agreement.

Please check agreements to enable the submit button.