Paramount Health Services (TPA) Pvt. Ltd.

Annexure A Form
Certificated From attending Doctor or Nursing Home /Hospital Doctor of Claimant
Sr.
No
1

Particulars

Details fill up by attending Doctor

Name of Patient

Age /Gender of Patient

Current Diagnosis

D.O.A. (With Time)

D.O.D. (With Time)

Since when patient is suffering From

Current Ailment.

Any Major Diseases Hypertension, Renal

diseases or any other, if yes please
specify with duration

Is the diseases suffered required

hospitalization.

Is the Hospital Registered with Local

authorities

10

No of bed in Nursing Home

11

Whether Fully Equipped OT Facility

available or not?

YES/NO

12

Whether Fully qualified Nursing staff

available or not?

YES/NO

13

Whether Qualified Doctor(s) incharge

available or not?

YES/NO

14

Any other Comments of the Treating

Doctor

YES/NO

Date:
__________________________
Signature of Attending Doctor
(With Name, stamp and Regn . No)