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.



Authorization 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 *

Completed By

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

Your email address

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