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manimalasree
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6 views

Form B

Uploaded by

manimalasree
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CLAIM FORM PARTB

TO BE PIRLLED IN BY THE HOSPITAL


8n admisslon of iability (Tobe Piled in
block letters)
The issue of thie Form is not
te be taken as
preauthorization request form in lHleu of PARTA
PHte inetute thie original
OETARS OF HOBPITAL

OOCOODOOO
V O R 6 O P p A O O D O D D O O O O C O O O O O O D O O D y 0 O O N

Name el he teelng decte

DETALSOF ThHE PATIENT A i

t mei s e ecmgele heie i h g e wmoher honpte Derenel

DETARS OF ARMENT DaONOSED PRIMARY)

CD 19 PCS erio

BvouCyte Procedure f

, Procedure 2
OOO0
Dometbite DOODO ,Procedure 3 OOO0
Comebitis ,Details of Procedure

Pre-authoricetion obined Yes No d) Pre-authorization Number OOOO0OOOOOOO


eauthoitebon by network hospital not obtained, give reason

Hospitolzation due to injury Yes N o Yes, give cause Self-inficted U Road Trafic Accident Substance abuse/ alcohol consumplian U
)tinuy due to substance abuse
/ alcohol consumption, Test conducted to establish this U Yes No
(11 Yes, atach reports). If Medico legat:Yes No vReporned to Police Yes
R OOOOOOOOO n If not reported to police give reason

CLAIMDOcUMENTS SUBMITTED CHECK LIST


Claim Form duly signed
Investigation repors
Onginal Pre-authorization request
CTMRIUSGIHPE investigation reports
C o p y of the Pre-auithoriz ation approval feer
Doctor's reference stlip for investigation
Copy of Photo ID Card of patient Verified by hospital ECG
Hospital Discharge summay Pharmacy bils
Dperation Theatre Notes
MLC repors &Police FlR
Hospital main bil
Original death summary from hospital where applicable
Hospital break-up ill
Any other, please specitly

DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hosptal


O2IADHCSAITALOD5123DDODPSAIAA5AIE E
BORODSIBediU6ADANeEALLEOOOOOOOOOOOOOL
C6DC
Chy
DEODOOOSate DAADOCRBCENANO
Pn Coe T323 b) Phone No.
D8sJH4230Ql03 Regstraton No. wih Stale Code GOOEW
d) Hospital PAN:
ALEG5o5B]E Mumber of ipatent beds6K Facitesavaliable the hospital OT Yes No CUAYes No
i. Others

DECLARATION BY THE HOSPITAL


(PLEASE READ VERY CAREFULLY)
We hereby decare that the information furnished in this Claim Form is true &correct to the best of outhrioyledag and peliet Uyhag pl6any false or untrue stalement, suppression or concealment of any material fact
Our right lo caim under this claim shal beforfeited

11.B.B.S., M.D, D.C.H, FC.c.P,


Date
2 2 UPTAKOSPITA
i pp. Sai Baba Temple
Place 4DANAYALEE SigaturihSAenAiuLlvQ47 325, A.PM
9. No. 6495

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