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Cost Certificate Form for Patients

The document is a Cost Certificate Form for patients, capturing essential details such as patient information, diagnosis, treatment costs, and hospital categories. It includes sections for diagnostic reports, current clinical status, and charity benefits. The form requires signatures from the treating doctor and includes hospital identification details.

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community.tshrc
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64 views1 page

Cost Certificate Form for Patients

The document is a Cost Certificate Form for patients, capturing essential details such as patient information, diagnosis, treatment costs, and hospital categories. It includes sections for diagnostic reports, current clinical status, and charity benefits. The form requires signatures from the treating doctor and includes hospital identification details.

Uploaded by

community.tshrc
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Date :

Cost Certificate Form


Patient Full Name

Age

Sex

Patients Adress in Details

Patients Contact Details

Daignosis / Organ System Involved Details

Daignostics Report to br attached ( yes / No )

Hospital Email ID

Treating Doctor, MMC Registration No / Unit Details

Cost of Traetment ( Surgical / medical )

Current Clinicle Status

Surgery Done (Yes/No)

Hospital Catogary- If P

A) RBSK/ADIP:

B) MJPJAY: (Procedure Covered, Yes Or No If Yes B) No

Then specify reason for apply

C) Charity ( Benefit of Charity Given or No If Yes C) Yes

Please Mention AmountOr Percentage If No specify

Reason Given Charity Benefits .

If Patient Admited - Date Of To Be Admited- Date of Surgery / If Possible Likely stay in terms of

Admission with Details Treatment Days

Hospital Stamp and Signature

(Treating Doctor /Concern Authority)

MMC Registration No.

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