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To be completed by Reception/Nurse:
Provider Name : Almoosa Specialist Hospital
Insurance/Corp : Bupa Middle East
TPA Name :
Patient File No : 3326742
Patient Name : Sadeen Ali Alibrahem
Plan Type : CLASS-B+
Mobile No : 0503929002
Date of Visit: 23-Sep-2018 Dept: Dermatology
þ Single ¨ Married ¨ Walk -in ¨ Referral
Mem. No: 15406086 Policy No: 359892001-359892002
To be Completed by attending PHYSICIAN: (Please tick ( ) ¨ Inpatient þ OutPatient / Emergency Case ? ¨ Yes ¨ No
Diagnosis Chronic
Approval Comments
Suggestive lines of management: Kindly enumerate the recommended investigation,and/or procedures for Outpatient approvals only
Total 61.40
I here by certify that ALL information mentioned are correct I hereby certify that all statements & information provided
& that the medical services shown on this form were concerning patient identification & the present illness or injury
medically indicated & necessary for the management of this are TRUE
Physician Signature & Stam
Provider : Mahmoud Mohammed Aboutabl
Dept : Dermatology Date : 24-Sep-2018 Name & Relationship (if guardian) Signature Date : 24-Sep-2018
* Provider's Approval/Coding Staff must review/ code the recommended service(s) & allocate cost and complete the following
For Insurance Company/TPA Use Onl ¨ Approved ¨ Not Approved Approval No. :
Comments (include approved days/service, if different from the requested) Approval Validity :
Insurance Officer: Signature: Date : / /