UCAF 1.

0
To be completed by Reception/Nurse:
Provider Name : Almoosa Specialist Hospital
Insurance/Corp : Bupa Middle East
TPA Name :
Patient File No : 3326742
Patient Name : Sadeen Ali Alibrahem
Plan Type : CLASS-B+
Mobile No : 0503929002
Date of Visit: 23-Sep-2018 Dept: Dermatology
þ Single ¨ Married ¨ Walk -in ¨ Referral
Mem. No: 15406086 Policy No: 359892001-359892002

To be Completed by attending PHYSICIAN: (Please tick ( ) ¨ Inpatient þ OutPatient / Emergency Case ? ¨ Yes ¨ No

BMI: 28.238 BP : Pulse : 89 Temp : 37.2

Duration of Duration : fewMonth(s)
Illness:
Chief Complaint & Main Symptom
pt with acne vulgaris come for follow up History of Present Illness: : pt with acne vulgaris come for follow up ;Duration : fewMonth(s)

Signs & Symptoms:

Skin Type : 4 ;Site of Lesion : face ;Skin Condition : normal ;local Examination ;pt with multiple papules and pustules involve the face
Diagnosis : L70.0-Acne vulgaris 23-SEP-2018 19:03

Diagnosis Chronic

Approval Comments

Suggestive lines of management: Kindly enumerate the recommended investigation,and/or procedures for Outpatient approvals only

Code * A Description/Service Quantity Type Cost*

SFDA110- N Vavo 2% 100ml Shampoo 1"S 1 Bottle Pharmacy 23.00

277-01

SFDA14-2 N Epiduo 0.1%/2.5% Gel 30gm 1 Tube Pharmacy 38.40

74-12

Total 61.40

Estimated Length of Stay : Days Expected Date of Admission :

Reason For Admission :
Remarks From Doctor :

- Is case Management Form(CMF1.0) included ¨ Yes ¨ No

Please specify possible line of management when applicable:

I here by certify that ALL information mentioned are correct I hereby certify that all statements & information provided
& that the medical services shown on this form were concerning patient identification & the present illness or injury
medically indicated & necessary for the management of this are TRUE
Physician Signature & Stam
Provider : Mahmoud Mohammed Aboutabl

Dept : Dermatology Date : 24-Sep-2018 Name & Relationship (if guardian) Signature Date : 24-Sep-2018

* Provider's Approval/Coding Staff must review/ code the recommended service(s) & allocate cost and complete the following

Total Cost : SR As estimated/Package Deal

Completed/Coded by : Signature: Date : / /

For Insurance Company/TPA Use Onl ¨ Approved ¨ Not Approved Approval No. :

Comments (include approved days/service, if different from the requested) Approval Validity :
Insurance Officer: Signature: Date : / /