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The document is an admission request note from Paramount Health Services Pvt Ltd for a patient seeking hospital admission. It contains: 1) Details of the patient like name, age, contact information and health insurance policy number. 2) Medical information provided by the treating consultant including presenting complaints, history, examination findings, investigations, diagnosis and proposed treatment plan. 3) Details of any pre-existing medical conditions. 4) Estimates of admission details, treatment costs and duration of stay provided by the hospital. 5) Authorization from the patient for Paramount to pay the hospital bills and reimbursement from the insurance claim.

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97 views

Paramount

The document is an admission request note from Paramount Health Services Pvt Ltd for a patient seeking hospital admission. It contains: 1) Details of the patient like name, age, contact information and health insurance policy number. 2) Medical information provided by the treating consultant including presenting complaints, history, examination findings, investigations, diagnosis and proposed treatment plan. 3) Details of any pre-existing medical conditions. 4) Estimates of admission details, treatment costs and duration of stay provided by the hospital. 5) Authorization from the patient for Paramount to pay the hospital bills and reimbursement from the insurance claim.

Uploaded by

disk_la_podu
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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PROVIDER NO.

PARAMOUNT HEALTH SERVICES PVT LTD (IRDA License No. 006)


Elite Auto House, 54-A, 2nd Floor, M. Vasanji Road, Mumbai 400 093 Tel: 022 5662 0808. Fax: 022 28259743

ADMISSION REQUEST NOTE

Annexure A

PART A- TO BE FILLED IN BY TREATING CONSULTANT


Name: Shri/ Smt/Kum: _______________________________________________Age: ________yrs. Sex: _____________
Patients Tel No. (Off) ______________ Fax (if any) _____________ Mobile no. ________________ Resi. Tel ___________
PHS ID. No: ____________________________ Corporate Name/ Emp Code: ____________________________________
Name of Treating Doctor: ________________________________________ Doctors Tel No: ________________________
Name Of Hospital / Nursing Home: _______________________________________________________________________
Name of Family Physician: ______________________________________________ Tel No.: ________________________
Presenting Complaints: ______________________________________________________________________________
History of Presenting complaints:________________________________________________________________________
Duration of presenting complaints: ____________________________________________________________________
Relevant Clinical Findings: ___________________________________________________________________________

___________________________________________________________________________________________________
___________________________________________________________________________________________________
Relevant past history & treatment: _______________________________________________________________________
Investigation Reports (attach separate sheet): -_____________________________________________________________
Provisional/Differential Diagnosis: ____________________________________________________________________
Proposed Treatment Plan (attach separate sheet): ________________________________________________________

______________________________________________________________________________________________________________
Particulars
Hypertension
IHD
Osteoarthritis
COPD/ Bronchial Asthama

Yes/ No

Since When

Any other Chronic Disorder

Particulars
Yes/ No
Since When
Diabetes
Heart Diseases (Date of First episode)
Cancer
Alcohol/Drug abuse
Maternity cases: Gravida______Para_____Living _____LMP_____

In c/o Accidents, influence of alcohol / any other drugs: Yes / No

Particulars
Date of admission
Approximate expenses
Room Rent
Investigation Charges
Name of Implant
Cost of Implant

Details

Whether MLC done: Yes / No

Particulars

Details

Approximate duration of stay


Class of accommodation
Doctor / Surgeon Fees
OT Charges/ Anesthesia/ Medicines
Package Rate
Total Amount

PART B TO BE FILLED BY THE HOSPITAL AUTHORITIES


Paramount will not be held liable for the payment in the event of any discrepancy between the facts presented at the
time of admission & in final documents submission.
Signature & Stamp of Treating Doctor: _________________Rubber Stamp Of Hospital & Signature ______________
PART C- TO BE FILLED UP BY THE INSURED
I have No Objection to Paramount obtaining details of my treatment / collecting documents and also hereby
authorize PHS to pay the hospital bill & reimburse itself / receive the amount from my claim receivable from my
insurance company. If my claim is rejected, I/we (the patient) will pay for the hospital & related expenses should this
authorization become null & void due to wrong and/ or misleading and/or incorrect information regarding the duration
of ailments and/or other historical information regarding my (patients) health status/. I acknowledge and agree that
information provided by me are true and up to the best of my knowledge.
Previous policy details Policy No._________________________ Insurance Company: _________________________
Previous claim details Ailment: ___________________Date: _________________Amount_______________________
Concurrent Policy details: ______________________________________________Contact Info:__________________
SIGNATURE/S.: _______________________________Name: _____________________________________________

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