Insurance
Insurance pre-approval request template
Reviewed against the Cooperative Insurance Companies Control Law — Regulator: Insurance Authority — Last reviewed: 6 November 2026
This template follows the law of Saudi Arabia, not the law of the United States or any other country. Naming the regulator identifies the law that applies; it does not mean the regulator approved this template. This is a general template and does not replace advice on your own case.
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Insurance Pre-approval Request
Date: Date
To: Insurance Company – Medical approvals
Please approve Procedure for patient Patient Name, membership No. Membership Number, diagnosed with Diagnosis, at an estimated cost of SAR Estimated Cost, as requested by Dr Physician Name.
Healthcare Facility – Contact Number