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[email protected] PRE‐AUTHORIZATION / CLAIM FORM FOR CASHLESS FACILITY
Patient Name: ____________________________ __________________ Health Card No.____________________________________________
Gender: Male Female Age: ___________ years Employee ID / Company Name __________________________________________
Patient Mobile No. ____________________________Expected Admission Date: ___________________Expected Length of Stay: ______days
Name of Treating Doctor: _________________________________________________ Mobile No: ________________________________
Name of Family Physician: ________________________________________________ Mobile No: _________________________________
Name of Hospital: ____________________________________________________________ City: _________________ ___________________
Details of presenting complaints: ________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Duration of Ailment: _____ years _____ months ______ days Provisional Diagnosis: ______________________________________________
Relevant Clinical Findings: _______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Investigations Report (if any): ___________________________________________________________________________________________
Proposed line of treatment during hospitalization: _________________________________________________________________________
_____________________________________________________________________________________________________________________
PAST HISTORY OF THE FOLLOWING WITH DURATION:
Disease / Ailment Past History Duration/ other details
Hypertension / Cardiovascular Diseases Yes No
Diabetes Yes No
Asthma Yes No
Any Surgery / Hospitalization Yes No
Any Other Disease / Disability Yes No
Obstetric History Yes No Status : G P A L LMP:
Intentional Self Injury Yes No
Accidental injury under the influence of Alcohol or Yes No
Intoxicating Drugs
Expense Head Amount (Rs.) Expense Head Amount (Rs.)
Room Rent Investigations
Doctor / Consultant visit charges Medicines / Consumables
Surgeon charges Equipment / Monitor etc
Operation Theatre Charges Miscellaneous (specify)
Package Charges Service Tax
Estimate of Expenses: Total Amount Rs. _____________________________ Class of accommodation: ____________________
I have completed this form and will be responsible for correctness of the medical information certified by me. I agree that Future Generali
shall not be liable to make payment in case of any discrepancy between the preauthorization form and discharge summary.
Signature of Doctor / Hospital Representative: ______________________________________________ Stamp / Seal of Hospital ___________
BENEFICIARY CONSENT / AUTHORISATION
I have ‘No Objection’ to Future Generali obtaining details of my treatment / collecting documents and also hereby authorize Future Generali
to pay the hospital bill from the sum insured of my insurance policy. I also undertake to pay all non medical / non authorized expenses in the
hospital bill directly to the hospital at the time of discharge. In case Future Generali issues "Denial of cashless facility" to the provider, I have
'No objection' in paying the hospital bill for the treatment given. All information provided above is true and I agree that if I have provided
any false or untrue information, my right to claim the expenses shall be absolutely forfeited.
NAME OF INSURED________________________________________________ SIGNATURE OF INSURED: ______________________
CMP001 – Preauthorization Form
