Preauthorization Request Form

PART I (To be filled by Policy Owner / Life Assured)

Insured Health Card No (MDID)*: Policy Number* (in full):
Name of the Policy Owner: _______________________ Name of the Patient*:__________________________________
Gender: Male Female Age:______ Yrs Relationship with the Policy Owner:___________
Policy Owner / Life assured number to be contacted: Mobile :____________________ Tel No:_____________________
Do you have any Family Physician? Yes No.
If ‘Yes’ Name:______________________ Contact No.:_____________

PART II (To be filled by Treating Doctor /Hospital)

1. Name and address of Hospital*:_____________________________________________________________________
________________________________________________________________________________________________
2. Hospital phone Number*:___________________Fax*:_________________Email ID:___________________________
3. Name of the treating doctor*:________________________Qualification*:___________Reg. No._______Contact No.:
4. Name of the referring doctor*:________________________Qualification*:___________Reg. No._______Contact No.:
5. The illness / disease / complaint for which hospitalization indicated:_______________________________________________________
6. Relevant Investigation Findings:_______________________________________________________ (attach Relevant Reports)

7. Relevant Clinical Findings:

B.P.: _______________ P/R:____________ Temp:________________CVS:____________
R.S.:_________________CNS:____________ P/A:__________________Others:__________

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8. Duration of present illness /disease ____________ a. Date of 1 Consultation____________ b. Tests done/ treatment taken
pre-hospitalization ________________________________________________________________________________________
b. Past occurrence of current ailment (If any):__________________________________________________________________
9. Provisional Diagnosis:____________________________________ 10. ICD 10 code:_____________________________
11. Proposed Line of Treatment Medical Management Surgical Management Intensive care
Non allopathic Invasive Investigation
a. If Medical Management, provide details:_________________________________________________________________
b. If Surgical, name of surgery:___________________________________________________ PCS Code____________
c. If invasive investigation, provide details: __________________________________________________________________________
d. If other line of treatment, provide details __________________________________________________________________
12. If an accident, is it RTA?: Yes No Date ____________ Reported to Police: Yes No FIR/MLC enclosed: Yes No
If ‘No’ reason for not reporting to Police :
If not reported, pl furnish name of police station applicable:_____________________________________________________________

13. Narrate the circumstances of the accident: ______________________________________________________________________

_________________________________________________________________________-
14. Is injury/ disease due to substance abuse/Alcohol consumption: Yes No (If ‘YES’ provide details & enclose relevant test reports)
15. In case maternity: Gravida______ Para____ Living Children____ Abortion_______ Year(s) of earlier delivery____________________

Fetal Death: ___________ LMP (Last Menstrual Period): _____________ EDD (Expected Date of delivery: _________________________
 16. Hospital admission details:
Type of Admission: Emergency Planned Day care; Probable Date of admission:_____________ Time:______hrs ____ mins
Expected number of days in hospital: Non ICU_____ Days ICU______ Days Room Type ________________
Past history of Chronic Illness (whether
Particulars of Hospital expenses COST treated or not) Details Duration
Room Rent + Nursing and Service charges + patient's diet Diabetes Mellitus YES/NO
ICU charges Heart disease (IHD/ RHD/ HOCM/ LVF) YES/NO
Doctor’s daily Visit Charges Hypertension YES/NO
Investigation and diagnostic charges Dyslipidemia YES/NO
Medicines and consumables Osteoarthritis (knee/ hip) YES/NO
Operation theatre charges Asthma/COPD/ Chronic Bronchitis YES/NO
Surgeon charges Cancer YES/NO
Anesthesia / Anesthetist charges HIV/STD related ailments YES/NO
If Implant to be used: details of implant (name, Habits: Alcohol Smoking Smokeless Tobacco
manufacturer)
Cost of implant Any other ailment provide details:
Package rate (if applicable)
Other charges
Service Tax
Total Cost of Hospitalization
PART III (Other Insurance Details of Policy Owner / Life Assured

1. Any other relevant information:_________________________________________________________________________________

2. Are you at present covered under any other similar type of insurance (Individual or Group Health Insurance, etc.) with BSLI or other
Insurance Company? Yes No. If yes, please provide details:

Policy No Name of insurance company Individual /Group Health Insurance Policy Issue Date Sum Assured

3. Other Preauthorization request / Reimbursement claim details under Policy/ies with BSLI or other Company (Current / past):

Insurance Company Ailment Admission date Preauthorisation / Date of decision Decision (Pay/Reject) Amount
Reimbursement claim

PART IV (Declaration Of The Policy Owner/Life Assured)

I have “No Objection” and hereby authorize BSLI/ MDIndia to obtain details of my treatment / collecting medical records or seek
additional/related information pertaining to my claim from the Hospital/Nursing Home. I acknowledge and agree that the information
provided by me with respect to complaints and past illnesses are true, complete and correct to the best of my knowledge and belief. I
understand and agree that in the event that any of the above details are found to be untrue or incorrect, MDIndia /BSLI (Company) has
the right to refuse my preauthorization request or where the authorization has already been given, refuse payment in respect of the
same. I further understand and agree that I shall be responsible and agree to bear the hospitalization and related expenses should this
authorization become null and void due to wrong and/or misleading and/ or incorrect information regarding the duration of the ailments
and/or of other historical information regarding my/ patient’s health status.

_______________________________ _________________________________________
Signature of Policy Owner with date Signature of Patient / Life Assured with Date
PART IV (Declaration Of The Hospital Authorities)
BSLI / MDIndia 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. All non medical expenses and expenses not relevant to the illness which is not payable by
BSLI/MDIndia should be directly collected from the patient. We have no objection to any authorised TPA/ Insurance Company official /
authorised representative verifying documents pertaining to hospitalisation.

Signature of treating Doctor (not RMO/ Casualty officer):_____________________ Seal of the Hospital

Instructions:
1. The Company will not be held liable for payment in the event of any discrepancy in information provided by the hospital at the
time of admission and network settlement (in final document submission)
2. If any details provided are insufficient/ incorrect, there may be delay/ denial of preauthorization (cashless) request.
3. Additional Information may be called for before authorizing for cashless facility
4. For cases other than emergencies, please send us the investigation reports and consultation papers along with pre authorization
request.
5. Denial of authorization does not mean denial of treatment and does not in any way prevent LA from seeking necessary medical
attention or hospitalization. Hence, irrespective of the TPA’s decision on the pre authorization request, it is advisable to LA to
avail health treatment as recommended by the treating doctor.
6. Any change in the diagnosis/ treatment plan / length of stay should be intimated to the Company before discharge of the life
assured and approval of the same shall be subject to Policy terms and conditions.
7. All the bills and claim form have to be duly signed by the patient before getting discharged.
8. Any request for authorization/enhancement made by the hospital after discharge of the life assured will not be considered.