chi_gov_sa · form · processed · 2 chunks
UCAF 2.0
To be completed & ID verified by the reception/nurse:
Provider Name:
The following table is a simple diagram:
Insurance Company Name:
TPA Company Name:
Patient File Number:
Dept:
Single ( )
Married ( )
Plan Type ( )
Date of visit
. / .
New visit (
) I Follow Up (
) I Refill
( )
) I Walk In (
) I Referral
(
To be Completed by the Attending PHYSICIAN: Please tick (√)
Inpatient ( )
Outpatient ( )
Emergency Case ( )
) I Emergency Care Level:
1 ( )
2 ( )
3 ( )
BP:
Pulse:
bpm
Temp:
°C
Weight: ..... Kg
Height: ....
cm
R.R:
Duration of Illness:
(Days)
Chief Complaints and Main Symptoms
Significant Signs:
Other Conditions
Diagnosis
Principal Code:
2 \( ^{nd} \) Code:
3 \( ^{rd} \) Code:
4 \( ^{th} \) Code:
Please tick ( √ ) where appropriate:
Chronic ( )
Congenital ( )
RTA ( )
Work Related ( )
Vaccination ( )
Check-Up ( )
Psychiatric ( )
Infertility ( )
Pregnancy ( )
Indicate LMP:
Suggestive line(s) of managmeet: Kindly, enumerate the recommended investigations, and/or procedures For outpatient approvals only:
<table><tr><td>Code</td><td>Description/Service</td><td>Type</td><td>Quantity</td><td>Cost</td></tr><tr><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td></tr></table>
Providers Approval/Coding Staff must review/code the recommended service(s) and allocate cost and complete the following:
Completed/Coded By
Signature
Date ..../..../
<table><tr><td>Medication Name (Generic Name)</td><td>Type</td><td>Quantity</td></tr><tr><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td></tr></table>
In Case managment Form (CMF1.0) included Yes ( ) 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 services shown on this form were medically indicated and necessary for the management of this case.
Physician
Signature
Stamp
Date
○
____/____/____
I hereby certify that ALL statements and information provided concerning patient identification and the present illness or injury are TRUE.
Name (and relationship (if guardian):
Date ____/____/____
Signature (*) Date ____/____/____
For Insurance Company 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