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    Treatment Guarantee Form (PP)

    Uploaded by

    Cinja Shidouji
    The document is a treatment guarantee form that must be completed by both a patient and their doctor to request insurance coverage for planned medical treatment. It requests important details like policy and patient information, treatment details, estimated costs, and signatures. Completing the form fully is necessary for the insurance company to guarantee coverage of the planned treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Treatment Guarantee Form (PP)

    Uploaded by

    Cinja Shidouji
    41 views2 pages
    The document is a treatment guarantee form that must be completed by both a patient and their doctor to request insurance coverage for planned medical treatment. It requests important details like policy and patient information, treatment details, estimated costs, and signatures. Completing the form fully is necessary for the insurance company to guarantee coverage of the planned treatment.

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    The document is a treatment guarantee form that must be completed by both a patient and their doctor to request insurance coverage for planned medical treatment. It requests important details like policy and patient information, treatment details, estimated costs, and signatures. Completing the form fully is necessary for the insurance company to guarantee coverage of the planned treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    41 views2 pages

    Treatment Guarantee Form (PP)

    Uploaded by

    Cinja Shidouji
    The document is a treatment guarantee form that must be completed by both a patient and their doctor to request insurance coverage for planned medical treatment. It requests important details like policy and patient information, treatment details, estimated costs, and signatures. Completing the form fully is necessary for the insurance company to guarantee coverage of the planned treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Treatment Guarantee Form

    Failure to complete this form fully will delay your insurance company’s ability to guarantee your treatment as they may
    have to revert to you or the medical provider for further information. The patient’s policy must be in force at the time of
    treatment. Please be advised that guarantee of payment is subject to the terms and conditions of the insurance policy
    and also subject to the assessment of all relevant documentation received, or yet to be received, by your insurance
    company in respect of this medical condition.

    Please be aware that it may be necessary to request further information before completing the Treatment Guarantee
    process. Thank you.

    Section 1 must be fully completed by (or on behalf of) the patient


    Section 2 must be fully completed by the doctor.

    1. PATIENT DETAILS - to be fully completed by (or on behalf of) the patient

    Policy Number:
    First name: Middle initials:
    Last name:
    Date of birth: (DDMMYYYY)

    Contact person please specify who should be contacted regarding this Treatment Guarantee request

    Name:
    Relationship to patient (e.g. self, spouse/partner, parent):
    Telephone (incl. country and area codes):
    Mobile telephone (incl. country and network codes):
    Email:

    2. TREATMENT DETAILS - to be fully completed by the medical provider

    If additional treatment is required, your insurance company must be notified.

    Medical Condition

    On what date would the first onset of symptoms have been apparent to the patient?
    (DDMMYYYY)
    Date of first attendance for this condition: (DDMMYYYY)
    Previous related treatment history:

    Description of the signs and symptoms:

    Diagnosis (if unknown, please state provisional diagnosis):

    ICD9/10 DSM IV DRG


    Treatment Plan

    Planned procedure/treatment details:

    Planned date of admission: (DDMMYYYY)


    Expected date of discharge: (DDMMYYYY)

    Please provide the following details for maternity cases:

    Date pregnancy confirmed by doctor: (DDMMYYYY)


    Expected or actual date of delivery: (DDMMYYYY)
    Delivery method:
    Is birth of a single baby expected? Yes  No 
    If No, is the pregnancy a result of medically assisted reproduction other than artificial insemination? Yes  No 

    Estimate Costs

    Estimated hospital charges (incl. currency):


    Estimated physician charges (incl. currency):

    Medical provider details

    Hospital/facility name:
    Address (incl. country):

    Email (mandatory):
    Telephone (incl. country and area codes):
    Fax (incl. country and area codes):

    Attending/admitting physician
    Name:
    Email:
    Telephone (incl. country and area codes):

    Please sign, date and authenticate with an official stamp.

    I confirm that all the details given in this form are, to the best of my
    Official stamp of medical provider
    knowledge, true, accurate and complete.

    Doctor’s signature:
    Date: (DDMMYYYY)

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