UCAF 2.0
To be completed & ID verified by the reception/nurse
Provider Name••••••••••••
Insurance Co.••••••••••
Patient File No••••••
DeptPediatric Clinic
Date of visit16 / 08 / 2026
Visit typeNew
Patient Name••••••••••••••
Phone••••••••••
Print/Fill in clear letters or Emboss Card
Insured Name••••••••••••••
ID. Card No••••••••••
Sex / AgeF / 0 Y
Policy Holder•••••••
Policy No••••
Expiry Date2027 / 02 / 05
ClassLM
Contract No480001
To be Completed by the Attending PHYSICIAN
Chief Complaint2 months, suffered from gases
Significant Signslax abdomen
Diagnosis: J00 — Acute nasopharyngitis (common cold)
| Code | Description of Service | Type | Qty | Cost |
|---|---|---|---|---|
| 130003 | Consultant examination — Pediatric | CONSULTATION | 1.00 | 150.00 |
| Total | 150.00 | |||
| Code | Medication Name | Amount | Type | Qty |
|---|---|---|---|---|
| 2812211518 | DEFLAT 40 MG/ML — DIMETICONE 40 drops | 10.25 | PHARMACY | 1.00 |
| 1006245400 | VIDROP — Vitamin D3 2800 IU drops | 9.30 | PHARMACY | 1.00 |
| Total | 19.55 | |||
For Insurance Company Use Only
Approved / Disapproved By
Not Enough Diagnosis
