POLMED ER24 Pre-Authorization 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: POLMED
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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