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Pre-Authorisation Request for
new medical condition only

 

Please provide as much detail as possible and note that items indicated with an asterisk must be completed. To submit your pre-authorisation request click the submission button at the end of this form. You will receive a confirmation email and a member of our claims team will be in contact within 24 working hours, we’re open from 06.00-18.00 (UK Time) Mon-Fri. If you need urgent treatment please click here for information about our emergency service.

Your Personal Details

Please complete the information requested and include supporting information via the document upload function

Your physician details
Please provide the contact details of medical practitioner who is most familiar with patients past medical history and confirm how long the patient has been registered with this doctor
Details of your current condition/symptoms
Clinical information
Additional information
Declaration
*This should be completed by the claimant’s parent or guardian if the claimant is a child under age 16, or by the claimant’s next of kin if the claimant is unable to provide properly informed consent due to cognitive disability or otherwise, or if the claimant is deceased. Please also state your relationship to the claimant and provide contact information.
*Our privacy policy contains information about how we use your personal information, who we share it with and your rights over how it is processed. For full details of our privacy policy, please visit www.william-russell.com/privacy/