Professional Documents
Culture Documents
Membership Number:
Suite
Deluxe Room
Others
Rs.
Rs.
Rs.
viii.OPD:
Rs.
xi.
Rs.
Note : Please enclose a cancelled cheque / copy of the same, NEFT cannot be facilitated without the cancelled cheque / copy
Date: D
Place:
SECTION H
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement,
suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance com pany, to seek necessary
medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have
included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.
GUIDANCE FOR FILLING CLAIM FORM PART A (To be lled in by the insured)
DATA ELEMENT
DESCRIPTION
FORMAT
Policy No.
b)
c)
d)
Name
e)
Address
Tick Yes or No
b)
c)
Company Name
Policy No.
Sum Insured
In rupees
Tick Yes or No
Date
Diagnosis
Previously Covered by any other Mediclaim/ Health
Insurance?
Company Name
Open Text
a)
d)
e)
f)
Tick Yes or No
Name of the organization in full
Name
b)
Gender
c)
Age
d)
Date of Birth
e)
f)
Occupation
g)
Address
h)
Phone No
i)
E-mail ID
b)
c)
d)
e)
Hospitalization due to
Date of Injury/Date Disease rst detected/ Date of
Delivery
Date of admission
f)
Time
g)
Date of discharge
h)
Time
i)
If Medico legal
Tick Yes or No
Reported to Police
Tick Yes or No
Tick Yes or No
j)
System of Medicine
Open Text
a)
b)
Tick Yes or No
c)
d)
PAN
b)
Account Number
c)
d)
e)
IFSC Code
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
GUIDANCE FOR FILLING CLAIM FORM PART B (To be lled in by the hospital)
DATA ELEMENT
DESCRIPTION
FORMAT
Name of Hospital
b)
Hospital ID
c)
Type of Hospital
d)
e)
Qualification
f)
g)
Phone No.
Name of Patient
b)
IP Registration Number
c)
Gender
d)
Age
e)
Date of Admission
f)
Time
g)
Date of Discharge
h)
Time
i)
Type of Admission
j)
If Maternity
Date of Delivery
Gravida Status
k)
a)
ICD 10 Code
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
Open text
Tick Yes or No
As allotted by TPA
Primary Diagnosis
Additional Diagnosis
Co-morbidities
b)
ICD 10 PCS
c)
d)
Pre-authorization obtained
e)
f)
Pre-authorization Number
If authorization by network hospital not obtained, give
reason
Hospitalization due to injury
Open text
Tick Yes or No
Cause
If injury due to substance abuse/alcohol consumption,
test conducted to establish this
Medico Legal
Tick Yes or No
Tick Yes or No
Reported To Police
Tick Yes or No
FIR No.
Open Text
g)
Tick Yes or No
Address
b)
Phone No.
c)
Registration No.
d)
PAN
e)
Digits
f)