: ******** : MOHAMED ALHELALI : ********

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +971******** Fax No. +971********) Doc Ctrl No.: LET/AUTH-036 Version No.: 1 Revision No.: 1 Date of Issue: 30.12.2012 Page No(s).: 1 of 2 Authorization Letter for Outpatient Service

Authorization Effective Date: 15/12/2020 Authorization Expiry Date: 12/01/2021 To:

Neuro Spinal

Hospital

Fax: +971********

Authorization No.: 78234306 Authorization Type:

INITIAL

CONCURRENT

Patient Details Service Details

Full Name:MOHAMED ALHELALI Place of Service: OUTPATIENT FACILITY/CLINIC Date of Birth:11/07/2003 Reference Number: INEM8906324 Product Name:UAE Armed Forces/NoMat

Daman Card Number:133*****-**

Policy Number:11499671

The below mentioned diagnosis is the interpretation of the information sent on the Authorization Request Form.

Code Diagnosis

ICD9CM Q03.1 Atresia of foramina of Magendie and Luschka Code Description of Services Service

Date

Requested

Quantity

Approved

Quantity

Quantity

Qualifier

ATC

GHQ Armed forces access to

care

15/12/2020 1 1

Comments

Dear Provider,

The requested services, if available in the provider contract, will be processed in accordance with the contractual terms.

kindly accept treating the member at your facility for 4 weeks Providers must ensure to accept the patient with this approval letter to be treated at the facility.The correct codes at the time of service must be sent to Daman using the electronic submission to avail the pre-authorization approvals for In patients and outpatient care based on the member Schedule of benefits.

Issue date: 16/12/2020

National Health Insurance Company – Daman (PJSC)

Medical Authorization Department

If service administered beyond Authorization Expiry Date: Expected new date: Signature of OPD/ other department: N.B: Please contact the National Health Insurance Company – Daman (PJSC) for date adjustment.

: 78234306 : MOHAMED ALHELALI : 11499671

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +971******** Fax No. +971********) Doc Ctrl No.: LET/AUTH-036 Version No.: 1 Revision No.: 1 Date of Issue: 30.12.2012 Page No(s).: 2 of 2 Authorization Letter for Outpatient Service

This is an electronically generated document, it does not require any signature or stamp.

Contact this candidate