Coringhy. yours. $Sprallan house Aor fon Ya Pe —40100. 865113 | CN-USSOOPNGOOOLCEISS reese ono: waning Sew) Emad: customecreasutanzcoin Tal ree no, 100-208-858, 02020205858 ER) “TO BE FILLEDIN BY THE HOSPITAL ‘The issue ofthis form is not ta be taken as admission of liability Please include the original preauthorization request frm inlieu of PART-A be ecn pockets) DETAILS OF HOSPITAL 3) Nameot the hospital ) Hospital: 6) pe ofhosital: Network ] Non Nework [] (tfnon-netvorfilsection ) 9) Nameot weating doctor ©) Qualifeation Registration No with tate Code 4) Phone No: 1) Rohini ode. 1) NABH CODE ) stateLeve Certfcate 1) Higher evel Crit 1) National Quality Assurance Standards, 1m) National Health System Resource DETAILS OF THE PATIENT ADMITTED 3) Name the patent ©) Presson ember conde Woe E]femle] dap eanL_| J wants ‘patti Lo Wh time [ALsub) — s)oxeeFdschawe: Lolo ffl vy] prime: [a |Lub 2) Spe otAdmsson: Emergency] Panne] Day Care Mate] Nateiy Date otdeen|o|0 ul vv) ipcreveastaus ) suusattneot che Dichagetohone [] dschageeaoterhseal[] veceased] 1m) alarmed Amount DETAILS OF AILMENT DIAGNOSED (PRIMARY) [EEE 01077 1) ateof aémision: [0 [> Jl aNol1o3s a) TED 10 codes Description ®) TED TORS Description 0 Primary Diagnosis i) Procedure i) Additonal Diagnosis iy Procedure? i) Comorbais LLL ip Procedures: LLL | W) Comorbatis i) Dataset Procedcre ©) Presuthorieton Obained: Yes] Ne] ©) Pe-Author2ation Number £) lfauthorzetion by network hospital no obsained ge reson sumption: i) fnjry de to Substance abusefalcohol consumption, Test conducted to establish ths: Yes] Nef] esatach epors) —w)edcoega es] No] @)Hospitazaton duetonjuy: Yes] No LC] ipfvesaive cause:Set-infited|(] Road iaffeAccdent [] Substance abse/ alcohol ce 9101035 ipepore toPotce Yes ]NoL] — yfiene: ifrotreportedto police ge reason (CLAIM DOCUMENTS -CHECK UST clam form dulysgnea Hi ingestion pons ovina tre-authorization request El crimejusciieeinvessigaion report LE copyotPre-ruthoration ete [Ey ocr reference sip forivestgation 2 By copyet phot 1 card of paint vere by hospital ec § 1 Hospital discharge summary Li Prarmacybits s operation tear notes micrepon aPolce At 5 Hespital main bit [L otigna dest summary rom hospital where applicable Host! breakup ei Li anyother lease specity [ADDITIONAL DETAILS INCASE OF NON NETWORK HOSPITAL (ONLY FIL IN CASE OF NON NETWORK HOSPITAL) 3) Adress ofhospitl ary, state 4) HosptaTPA i) thers: DECLARATION BY THE HOSPITAL: (PLEASE READ VERY CAREFULLY) ‘Wie hereby declare that the information urished nthe Claim Forms we and correct othe bes af our know/edge andl. we have made any fale and uniue statement, suppression or cncealment of any materia fact, or right dai under this dam sll be frfoted ate Pace Phone No ©) Registration nowt tate Code aientbeds|_| | fecivesavaablernbospta Jor: YesL_JNoL_} — ijteuses LTNoL] I) No1L93s NES NoU93 Signature and Sealof the Hospial Authority‘GUIDANCE FOR FILLING CLAIM FORM PART (Tobe led in bythe! Tospital) ‘DATAELEMENT DESCRIPTION. FORMAT SECTION A- DETAILS OF HOSPITAL ‘Name of ospad Enver Rename of hospital Tame oThospiain ful E)Hospital 1D Enter D number ofthe hospal ‘allocated by TPA ype of Hospital Tndicate whether in network or nan network hospital “Tickthe right option ‘Name of Treating doctor Enver the name of eating doctor Name ofdectoria full ‘)Qualifcation Enter the qualification ofteating doctor abbreviations of educational qualifications 1 Regatration No with sate code Ente he regsation no of eating doctor along with state code As allocated by the meacal council india Phone Ne Enter the phone no of docor Thelude STO code wth telephone number ‘SECTION B- DETAIIS OF THEPATIENT ADMITTED. a) Name ofthe patient Enter the name of hospital Name ofhosptain ull BP Registration number Enter the nsurance provigeregataion number ‘As aocated by the insurance pro e)cender Tndicate Gender ofthe patient Tick Mile or Female ‘ase te age ofthe patient Number of years and month e)oateoT oA Enter date of admission Use ede format 1) Date of Admission Enter date of admission Use éd-meyy format ‘ime Enter date of admission Use Rim format ‘YD of Daharge Tote date of discharge Tie dd-mry Format Time Ener ume of ascharge Use zm format 1) ype of Asan Thdicate type ofadmion of patient Tickthe right option Maternity Date of Delvery Erie Date of Delvery Irmateriy Tie deem format ‘Gavia Statue Enter Gravida status ifmateriy Use standard format TT status atime of iecarge Indicate satus ofpatent atime of dscharge Tiekthe right option ‘)Total claimed amount Indicate the total claimed amount Tn rupees (Do not enterpavevalues) SECTION C- DETAILS OF ALMENT DIAGNOSED (PRIMARY) ID tad Primary Diagnosis Ente he [OD TO Cade and description af he primary Gagnon ‘Seandard Format and Open tet ‘Aadional agnosis Enter the ICD T0 Code and description ofthe additonal dlagneh ‘Standard Format and Open text ‘Co-morbdites Enter the ICD 10 Code and description of the co-morbidites ‘Standard Format and Open text B) IED TOPCS Procedure 1 Ee he ICD TOPS and description ofthe is procedure ‘Siandard Format and Open te Procedure? Enter the ICD 10 °CS and description ofthe second procedure ‘Standard Format and Open tex Procedure 3 Enter the ICD TOPCS and description ofthe third procedure “Standard Format and Open text Details of Proceaure Enter the details of the procedure ‘Opentext ©) Pre-authorzavion obtained Indicate whether pre-authorzabon obtained Tick Yes oF Wo )Preauthorration Number Ente pre-authorization number Realored by TH ©) Fauthorzation By network Enter eason for not obtaining pre-authorization number ‘Opentext hospital not obtained sie reason 1) Hospitalization due to injury Tadicate i hespaliaton W due te ruyy Tie Ves or We Cause Indicate cause of uy Ticktie right option injury de to substance abuse] alcohol consumption test, conducted to establish this Indicate whether test conducted Tick Yes No Medico Lega Traeate whether njuny is meee Teg TekYerorNo Reported To Police Indicate whether police report was filed Teck Yes oF No FRM Ente Frstinformation report number 7s issued by pace authors Tinot repared to pacegive reason | enter reason fr not reporting to poice ‘Open Text SECTION D. CLAIM DOCUMENTS SUBMITTED-CHECKLIST Indicate which supporting documents are submitted ‘SECTION E- DETAILS IN CASE OF NON NETWORK HOSPITAL Address Enter the fll postal adres Tndlode Stee, Cigyand Pin Code ByPhone Na; rier he phone number of Rosptal Trude STO code with telephone number “ORESiaaGN No with Sate Code Ener the regation numberof he doctar slong with ‘As allocated by the Medical the sate code Council of ng “Hospital PAN Enter he permanent account number ‘Asallotted bythe Income Tax department ‘Number ofinpatient ede Enter te number of patent bade Dias 1) Facies avaiable inthe Rospial dicate facies available inthe hospal Tickthe rghtopiion, Fothers please specify SECTION F - DECLARATION BY THE HOSPITAL Read declaration careuly and meni jan dae (in deimmay format, place (open tex) andaign andtamp