ER24 Pre-Authorisation Request Form

Disclaimer: The authorisation is not a guarantee of payment and is still subject to a comprehensive membership validation, scheme rules, funding criteria, benefit limits etc.


Authorisation Requestor *
 
 

Patient Information
Medical Aid Scheme *

Membership Number *
Dependent Code

Patient Surname *
Patient Name *

Patient RSA ID Number  *
Patient Date Of Birth  *

Gender *
 
 
 

Level of Care
Diagnosis  *

Pick Up Address *
Drop Off Address *


Ambulance Company Name *
Service Date *

Patient Report Form Number or Reference

Completed By

If you would like us to send you the Authorisation number via email, please complete the following:

Your email address


Cancel