Pre Authorisation Form
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PLEASE GIVE 72 HOURS NOTICE FOR PRE-AUTHORISATIONS Member’s Name : ___________________________________ Membership Number : ___________________________________ Name of Procedure : ___________________________________ ____________________________________ ____________________________________ Date of Birth : ____________________________________ Group Name and Number : ____________________________________ Date of Procedure : ____________________________________ Name of Doctor/Surgeon : ____________________________________ Name of Hospital/Clinic : ____________________________________ Number of nights staying in hospital: ____________________________________ Diagnosis : ____________________________________ What symptoms are you experiencing: ____________________________________ ____________________________________ ____________________________________ When did your symptoms start : ____________________________________ PLEASE EMAIL COMPLETED FORM TO BUPA ADVISOR OFFICE: [email protected] or [email protected] REQUEST FOR PRE-AUTHORISATION An authorisat ion cannot be arranged
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Transcript of Pre Authorisation Form
REQUEST FOR PRE-AUTHORISATION
Please give 72 hours notice for pre-authorisations
Members Name:___________________________________
Membership Number:___________________________________
Name of Procedure: ___________________________________
____________________________________
____________________________________
Date of Birth:____________________________________
Group Name and Number:____________________________________
Date of Procedure:____________________________________
Name of Doctor/Surgeon:____________________________________
Name of Hospital/Clinic:____________________________________
Number of nights staying in hospital:____________________________________
Diagnosis:____________________________________
What symptoms are you experiencing:____________________________________
____________________________________
____________________________________
When did your symptoms start:____________________________________
Please email completed form to Bupa Advisor Office:An authorisation cannot be arranged if the details on this form are incomplete.
[email protected] or [email protected]
**Please note pre-admissions to hospitals may not be covered, this is reviewed by Bupa International on a case by case basis. A medical report may be required.In order to be prepared please have cash ready in case of the pre-admission not being covered.**
1. Pre-authorisations must be arranged before the treatment takes place, they cannot be arranged once treatment has taken place.
2. The pre-authorisation form must be completed in full, Bupa require all information on this form and a pre-authorisation will not be arranged if there are details are missing.
3. Please note Bupa Global may request a medical report depending on the treatment. Bupa Global is the insurer and they make the decisions on pre-authorisations not this office.
4. Pre-authorisations require 72 hours notice except in case of an emergency.
5. For treatment in South Africa, please contact Bupas Service Partner, MSO on +27 11 259 5402 or [email protected] for pre-authorisation. In South Africa there is a toll free number for Bupa that you can use from a South African landline:Country Free Phone Numbers to Bupa Global in UK from South African landlines:Customer Service Number : 0 800 982 043 Medical Assistance Number: 0 800 982044
The Bupa Adviser office is open:Monday to Thursday 9am 4pmFridays 9am 3pm(no public holidays or weekends)
Bupa Global is the Insurer and are open 24 hours, 365 days a yearPre-authorisations +44 1273 323563 (24 hrs)Evacuation and Medical Advice +44 1273 333911 (24 hrs)[email protected]
