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.

1. Patient Details:

   • Full Name: [Your Name]

   • Date of Birth: [DOB]

   • Policy/Member Number: [Number]

   • Diagnosis: [Primary Diagnosis, e.g., Hepatocellular Carcinoma]

2. Proposed Treatment & Provider:

   • Treating Hospital: [Hospital Name, e.g., The First Affiliated Hospital, Zhejiang University]