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
Please indude the original preauthorization request form in lieu of PART A
DETAILS OF HOSPITAL (To be filled in block letters)
a) Name of the hospital:
(If non network fill section E)

SECTION A
b) Hospital ID: c) Type of Hospital: Network Non Network
d) 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

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

f) Date of Admission: D D M M g)Time: H H M M h) Date of Discharge: D D M M i)Time: H H M M

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

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

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD10 Codes Description b) ICD 10 PCS Description

i. Primary Diagnosis: i. Procedure1:

ii. Additional Diagnosis: ii. Procedure2:

iii. Co-morbidities: iii. Procedure3:

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

SECTION D
Copy of the Pre-authorization approval letter Doctor’s reference slip for investigation

Copy of photo ID card of patient verified by hospital ECG

Hospital Discharge summary Pharmacy bills

Operation Theater notes MLC report & Police FIR

Original death summary from hospital where applicable
Hospital main bill
Hospital break-up bill Any other, please specify

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

a) Address of the hospital:

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

d) Hospital PAN: e) No of Inpatient beds f) Facilities available in the hospital: [Link]: Yes No ii. ICU: Yes No
SECTION E

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.

Date: D D M M
SECTION F

Place:

Signature and Seal of the Hospital Authority: