Appendix E: Insurance Pre-authorization Request Template
Email this to your insurer's pre-authorization department, filling in the [brackets].
SUBJECT: Pre-Authorization Request for Medical Treatment in China - [Patient Name], Policy #[Number]
Dear [Insurance Company] Pre-Authorization Team,
I am writing to request a Guarantee of Payment (GOP) for planned medical treatment at a hospital in China.
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Patient Details:
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Full Name: [Your Name]
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Date of Birth: [DOB]
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Policy/Member Number: [Number]
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Diagnosis: [Primary Diagnosis, e.g., Hepatocellular Carcinoma]
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Proposed Treatment & Provider:
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Treating Hospital: [Hospital Name, e.g., The First Affiliated Hospital, Zhejiang University]
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Hospital Address: [Full Address in China]
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Treating Physician: [Dr. Name, Title] - [Specialty]
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Proposed Treatment: [e.g., Laparoscopic hepatectomy and postoperative care]
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Proposed Dates of Service: [Admission Date] to [Estimated Discharge Date]
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Attached is the hospital's official treatment plan and cost estimate.
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Medical Necessity:
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I have been diagnosed with [Diagnosis]. The proposed treatment is medically necessary because [brief reason, e.g., "it is the standard curative-intent therapy for this stage of disease" or "all first-line treatments in my home country have been exhausted"]. My medical records, including imaging and pathology reports, are attached for your review.
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Financial Information:
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The estimated total cost provided by the hospital is [Total in Local Currency & USD]. Please issue the GOP letter to the hospital's International Department to facilitate direct billing.
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Hospital Billing Contact:
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Department: International Medical Center
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Contact Person: [Name]
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Email: [Email]
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Phone: [Phone with Country Code]
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Please advise on the next steps and confirm if any additional information is required. I can be reached at [Your Phone] or [Your Email].
Sincerely,
[Your Name]
Attachments: 1. Hospital Treatment Plan & Cost Estimate, 2. Medical Records Summary, 3. Key Imaging/Pathology Reports.