24 Hour Emergency Lines

0737 711 633 / 0773 353 308 / 0710 607 333 / 020 353 5308
0736 372 881 (Mombasa) / 0733 154 415 (Kisumu)
Email:careteam@gakenya.com

REST ASSURED
INPATIENT PRE-AUTHORIZATION FORM
This form should be completed in BLOCK LETTERS, signed by the member and the doctor on whose
Recommendation the treatment was undertaken, and thereafter returned to us with all relevant documents
and vouchers supporting these expenses attached.
PART 1 (MEMBER TO FILL)
Company Name _________________________________________________ Staff No. ___________________
Member Name _______________________________ Telephone No. _________________________________
Patient Name ___________________________________ Card No. ___________________________________
Relation to Member Self Spouse Son Daughter Age ______yrs
Are you a member of National Hospital Insurance Fund? Yes No
Are you insured under any other insurance scheme? Yes No

PART II (DOCTOR TO FILL)

Diagnosis ____________________________________ Cause of illness ________________________________
Is the condition recurrent? Yes No Is the condition congenital Yes No
Clinical summary ___________________________________________________________________________
_________________________________________________________________________________________
Has the patient been tested for HIV? (If yes, give details) Yes No
_________________________________________________________________________________________
Is this the first Ceserian operation? (If yes, give details of what necessitated) Yes No
_________________________________________________________________________________________
Is it an Elective or Emergency Ceserian Operation? Yes No
Clinical summary / indication ________________________________________________________________
Treatment given and Recommendations _______________________________________________________
_____________________________________________________________________________
Doctor’s Fee: ____________________________ Estimated hospital stay _________________ Hospital/
Name of Doctor: _________________________ Qualification of the Doctor: ______________ Doctor
Stamp
Telephone No: ___________________________ Signature of Doctor____________________

PART III (PATIENT CONSENT)

I __________________________________ hereby confirm that I have on my own accord chosen to use a doctor who is not on
the preferred provider panel of GA Insurance Ltd/ be hospitalized in a room that is above my bed limit with GA Insurance Ltd. I
fully understand the implications of my decision and hereby undertake to pay the hospital/ doctor any amount that exceeds the
limit set by GA Insurance Ltd.
I understand that the amounts are payable on demand and not later than the time of discharge.

PART IV (PATIENT DECLARATION)

I declare that all the statements given by me on this form are to the best of my knowledge true and complete.
I authorize the Insurance Company to obtain medical information from the doctor I have consulted and shall submit to any
medical examination(s) if so required by the Company.

Name __________________________________ ID No. __________________ Telephone No. _______________________

Signature _______________________________ Date ______________________________________________________

GA Insurance Limited, GA Insurance House, Ralph Bunche Road, P.O. Box 42166 - 00100 Nairobi, Kenya