REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY

PART C(Revised)
(TO BE FILLED IN BLOCK LETTERS)

DETAILS OF THE THIRD PARTY ADMINISTRATOR/ INSURER/ HOSPITAL

Name of the Hospital: PANACEA HOSPITAL

CC-61, OPPOSITE PATLIPUTRA SPORTS COMPLEX, LOHIYA

Hospital Location: Hospital ID:
NAGAR, KANKARBAGH

Hospital email ID: [email protected] ROHINI ID: 8900080525344

DETAILS OF THIRD PARTY ADMINISTRATOR: (To be Filled in block letters )

a) Name of TPA /
MEDI ASSIST INSURANCE TPA PVT LTD b) Phone Number: 080 22068666 c) Toll Free Fax no: 1800 425 9559
Insurance company:

TO BE FILLED BY INSURED/PATIENT

a. Name of the Patient: SAROJ KUMAR

b. Gender: c. Contact no: +91 993 1720 818 d. Alternate Contact no:
MALE FEMALE THIRD GENDER

g. Insured Card ID
e. Age: (Years) / (Month) f. Date of Birth: (DD/MM/YYYY) 5121513472
number:

h. Policy number/Name of Corporate: 91534535 i. Employee ID: 22957

j. Currently do you have any other mediclaim /health

YES NO j.1) Insurer name:
insurance:

j.2) Give Details:

k. Do you have a family Physician: YES NO k.1) Contact no:

l. Occupation of insured patient:

m. Address of insured patient:

TO BE FILLED BY TREATING DOCTOR/HOSPITAL

a. Name of the treating doctor: SHIV SHANKAR PRASAD b. Contact Number:

c. Nature of Illness/Disease d. Relevant LRTI

with presenting complaint: Critical Findings:

e.1) Date of First

e. Duration of the present ailment Days (DD/MM/YYYY)
consultation:

e.2) Past history of present aiment, if any:

LRTI f.1) ICD 10

f. Provisional diagnosis:
code:

g. Proposed line of treatment

Medical Management Surgical Management Intensive Care Investigation Non-Allopathic Treatment

h. If investigation and/or Medical Management provide details h.1) Route of Drug Administration:
IV Oral Others

i. If surgical, name of surgery i.1) ICD 10 PCS code:

j. If other treatment, provide details CONSERVATIVE MANAGEMENT k: How did injury occur

l. In case of accident i.Is it RTA: ii.Date of Injury: (DD/MM/YYYY)

YES NO

iii.Report to Police: iv.FIR NO:

YES NO

v. Injury /Disease caused due to substance abuse/alcohol consumption

YES NO

vi. Test conducted to establish this(if yes, attach report)

YES NO

m. In case of maternity: G P L A n. Expected date of delivery (DD/MM/YYYY)

Details Of The Patient Admitted

a. Date of admission: 02-06-2025 b. Time: 04:05 PM c. This is:
EMERGENCY planned
d. Expected no.of days in hospital : 4 Days e. Days in ICU: f. Room Type

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 REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY
PART C(Revised)

g. Per Day Room Rent + Nursing &Service Charges +

Rs. 12000
Patient's Diet:
Mandatory: Past History of any chronic
illness (If yes, since (month / year)
h. Expected cost for investigation + diagnostics: Rs. 10000

1.Diabetes
i. ICU Charges:

j. OT Charges: 2.Heart Disease

k. Professional fees Surgeon + Anesthetist Fees + 3.Hypertension

Rs. 5000
consultation charges:

l. Medicines + Consumables + Cost of Implant

4.Hyperlipidemia
Rs. 25000
specify):
5.Osteoarthritis
m. All inclusive package charges if any applicable:
6.Asthma / COPD / Bronchitis
n. Other hospital expenses if any Rs. 15000

67000 7.Cancer
o. Sum Total expected cost of hospitalization: Rs.

8.Alcohol or drug abuse

9.Any HIV or STD / Related

ailments
10.Any other Ailment give details:

DECLARATION

We confirm having read understood and agreed to the Declaration on the reverse of this form

a) Name of the treating doctor: SHIV SHANKAR PRASAD

b) Qualification: c) Registration No. with State Code:

DECLARATION BY THE PATIENT/REPRESENTATIVE

a. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TPA after the discharge. I agree to sign on the Final Bill & the Discharge Summary, before my
discharge.
b. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / TPA is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions
of the policy.
c. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the Insurer/TPA not governed by the terms and conditions of the
policy will be paid by me.
d. I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect I forfeit my claim and agree to indemnify the insurer /
TPA
e. I agree and understand that TPA is in no way warranting the service of the hospital & that the Insurer / TPA is in no way guaranteeing that the services provided by the hospital will be of a particular
quality or standard.
f. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment with respect to the claim,
my right to claim reimbursement of the said expenses shall be absolutely forfeited.
g. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer/ TPA.
h. "I/We authorize Insurance Company/TPA to contact me/us through mobile/email for any update on this claim"
a) Patient's / Insured's Name: SAROJ KUMAR

b) Contact
+91 993 1720 818 c) Email ID: (Optional): [email protected]
number:

d) Patient's / Insured's Signature: Date: Time:

HOSPITAL DECLARATION
a. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization.
b. All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA/ Insurance Company within 7 days of the patient?s discharge.
c. We agree that TPA / Insurance Company will not be Liable to make the payment in the event of any discrepancy between the facts in this form and discharge summary or other documents.
d. The patient declaration has been signed by the patient or by his representative in our presence.
e. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications.
f. We will abide by the terms and conditions agreed in the MOU.
g. We confirm that no additional amount would be collected from the insured in excess of Agreed Package Rates except costs towards non-admissible amounts (including additional charges due to opting
higher room rent than eligibility choosing separate line of treatment which is not envisaged/ considered in package).
h. We confirm that no recoveries would be made from the deposit amount collected from the lnsured except for costs towards non-admissible amounts (including additional charges due to opting higher
room rent than eligibility/ choosing separate line of treatment which is not envisaged/considered in package).
i. In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed Package Rates, the authorized TPA / Insurance Company reserves the right to recover the same
from us (the Network Provider) and,/or take necessary action, as provided under the MOU or applicable laws.

Hospital Seal Doctor's Signature

Date: Time:

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed Discharge Summary and all Bills from the hospital.

2. Cash Memos from the Hospitals / Chemists supported by proper prescription.
3. Receipts and Pathological Test Reports from Pathologists, Supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests
4. Surgeon's Certificate stating nature of Operation performed and Surgeon?s Bill and Receipt.
5. Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured
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