CLAIM FORM - PART B

TO BE FILLED IN BY THE HOSPITAL

The issue of this Form is not to be taken as an admission of liability (To be Filled in block letters)
Please include the original preauthorization request form in lieu of PART A
DETAILS OF HOSPITAL

a) Name of the hospital:

SECTION A
a) Hospital ID: c) Type of Hospital: Network : Non Network : (if non network fill section E)

c) Name of the treating doctor: S U R N A M E F I R S T N A M E M I D D L E N A M E

e) Qualification: f) Registration No. with State Code: g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient: S U R N A M E F I R S T N A M E M I D D L E N A M E

b) IP Registration Number: c) Gender: Male Female d) Age: Years Y Y Months M M e) Date of birth: D D M M Y Y

SECTION B
f) Date of Admission: D D M M Y Y g) Time: H H M M h) Date of Discharge: D D M M Y Y H H M M

j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity i) Date of Delivery: D D M M Y Y ii) Gravida Status: :

I) Status at time of discharge: Discharge to home Discharge to another hospital Deceased m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

I. Primary Diagnosis i. Procedure 1:

ii. Additional Diagnosis: ii. Procedure 2:

iii. Co-morbidities: iii. Procedure 3:

SECTION C
iv. Co-morbidities: iv. Details of Procedure:

c) Pre-authorization obtained: Yes No d) Pre-authorization Number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to injury: Yes No I. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption

ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this: Yes No (If Yes, attach reports) iii. If Medico legal: Yes No iv. Reported to Police Yes No

v. FIR No. vi. If not reported to police give reason:

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed Investigation reports

Original Pre-authorization request CT/MR/USG/HPE investigation reports
Copy of the Pre-authorization approval letter Doctor’s reference slip for investigation

SECTION D
Copy of Photo ID Card of patient Verified by hospital ECG

Hospital Discharge summary Pharmacy bills

Operation Theatre Notes MLC reports & Police FIR
Hospital main bill Original death summary from hospital where applicable
Hospital break-up bill Any other, please specify

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital

City: State:
SECTION E

Pin Code: b) Phone No. c) Registration No. with State Code:

d) Hospital PAN: e) Number of inpatient beds f) Facilities available in the hospital i. OT Yes No ii. ICU Yes No

iii. Others:

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

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, suppression or concealment of any material fact,
our right to claim under this claim shall be forfeited.
SECTION F

Date: D D M M Y Y

Place: Signature and Seal of the Hospital Authority: