Beruflich Dokumente
Kultur Dokumente
SECTION A
d) Name:
SECTION A
e) Address:
City:
State:
Pin Code:
Phone No:
Email ID:
Yes
No
d) Have you been hospitalized in the last four years since inception of the contract?
Diagnosis:
Yes
No
Date:
Yes
No
SECTION B
Male
Female
Self
Service
Self Employed
months
Child
Homemaker
d) Date of Birth:
Father
Mother
Other
(Please specify)
Student
Retired
Other
(Please specify)
SECTION C
f) Occupation:
c) Age: years
Spouse
City:
State:
Pin Code:
Phone No:
Email ID:
DETAILS OF HOSPITALIZATION
a) Name of Hospital where Admitted:
b) Room category occupied:
Day Care
Injury
Single occupancy
Illness
e) Date of Admission:
i) If injury, give cause:
ii. Reported to police:
Yes
g) Date of Discharge:
f) Time:
Self inflicted
Twin sharing
Maternity
Yes
No
h) Time:
i. If Medico Legal:
Yes
No
SECTION D
j) System of medicine:
DETAILS OF CLAIM
Claim Documents Submitted- Check List:
v. Ambulance Charges
Total
days
Yes
No
ECG
iv. Convalescence:
vi. Others:
Total
SECTION E
Sl. No.
Bill No.
Date
Issued By
Towards
Hospital Main Bill
Pharmacy Bills:
5
6
Amount (`)
SECTION F
7
8
9
10
DETAILS OF PRIMARY INSURED'S BANK ACCOUNT
b) Account Number:
SECTION G
a) PAN:
SECTION G
e) IFSC Code:
Date:
Place:
DATA ELEMENT
DESCRIPTION
FORMAT
Enter the social insurance number or the certificate number of social health
insurance scheme
d) Name
e) Address
Tick Yes or No
c) Company Name
Policy No.
Sum Insured
In rupees
d) Have you been Hospitalized in the last 4 years since inception of the contract?
Tick Yes or No
Date
Diagnosis
Open Text
Tick Yes or No
f) Company Name
b) Gender
c) Age
d) Date of Birth
f) Occupation
g) Address
h) Phone No
i) E-mail ID
c) Hospitalization due to
e) Date of admission
f) Time
g) Date of discharge
h) Time
If Medico legal
Tick Yes or No
Reported to Police
Tick Yes or No
Tick Yes or No
j) System of Medicine
Open Text
Tick Yes or No
b) Account Number
Enter the name of the beneficiary the cheque/ DD should be made out to
e) IFSC Code
SECTION H
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this
claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is
made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.
SECTION A
DETAILS OF HOSPITAL
a) Name of the Hospital:
c) Type of Hospital:
Network
Non Network
SECTION A
c) Hospital ID:
d) Name of the treating doctor:
e) Qualification:
g) Phone No.
f) Date of Admission:
g) Time:
j) Type of Admission:
Emergency
Planned
Discharged to home
Day Care
Male
Female
d) Age: years
months
e) Date of Birth:
h) Date of Discharge:
Maternity
k) If Maternity:
i) Time:
i. Date of Delivery:
SECTION B
b) IP Registration No.:
Deceased
ICD 10 Codes
Description
b)
ICD 10 PCS
i. Procedure 1 :
ii. Procedure 2 :
iii. Co-morbidities :
iii. Procedure 3 :
iv. Co-morbidities :
Yes
No
Description
SECTION C
i. Primary Diagnosis :
d) Pre-authorization number:
Yes
No
Self inflicted
ii. If injurydue to Substance abuse / alcohol consumption, Test Conducted to establish this:
v. FIR No.
Yes
Yes
No
Yes
No
Yes
No
ECG
Pharmacy bills
SECTION D
DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)
a) Address of the hospital:
SECTION E
City:
State:
Pin Code:
b) Phone No:
d) Hospital PAN
i. OT:
Yes
No
ii. ICU:
iii. Others:
DECLARATION BY THE HOSPITAL
Date:
Place:
GUIDANCE FOR FILLING CLAIM FORM PART B (To be filled in by the hospital)
DATA ELEMENT
DESCRIPTION
FORMAT
b) Hospital ID
c) Type of Hospital
e) Qualification
Enter the registration number of the doctor along with the state code
g) Phone No.
SECTION F
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppress or concealment of anu material fact, our right to claim under this claim shall be
forfeited.
b) IP Registration Number
c) Gender
d) Age
e) Date of Admission
f) Time
g) Date of Discharge
h) Time
i) Type of Admission
Date of Delivery
Gravida Status
j) If Maternity
Additional Diagnosis
Co-morbidities
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
Open text
c) Pre-authorization obtained
Tick Yes or No
d) Pre-authorization Number
As allotted by TPA
Open text
Tick Yes or No
Tick Yes or No
Medico Legal
Tick Yes or No
Reported To Police
Tick Yes or No
FIR No.
Open Text
b) ICD 10 PCS
Cause
If injury due to substance abuse/alcohol consumption, test conducted to establish this
b) Phone No.
Enter the registration number of the doctor along with the state code
d) Hospital PAN
Digits