HEALTH Health Claim Form

NSURANCE

Part B

o be filled in by the hOspItal,

2 . The issue of this Form is not to be taken as an admission of liabiIIty.
3. Please InCIUde the OrIgInal pre.authorIzatIon request form in IIeu of PART A.
4. Tobe filled in black letters.

Section A - Details of HospItal

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b) HOSPMIID : LTITT:ITII]
c) Type of HospItal : I Network _J Non-netvwrk (if non-neW>rkfill section E)

d) N,m, ,[th, u,dngd„t,r , lm{ [-EL}I N b:l I}]{] U- T lot Lqvfl~

e) QuaIIfication

f ) Registration No. with State Code 1;A

it IP t &;;ii .] }IS P:i ;i1 1 %Jr\]i\r M L 1 MEf•

g) Contact No.

Section B - Details of the Patient Admitted

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b) IP Rednrdor\ No. : 3 1 ST [T T I I I I I 11' i ’I"!
C) Gender : /M :– F d) Age :
1/== d-iiI,r&M: \ q =/ (i C ; AC) I C
r) D,t,,fAd„„„,. , \ S/ aq/ LOUd frn1 g) Time ofAdmision: Bl : O 1 PM
'Y i) Time of Discharge
h) D,t,,fD',h,rg, , \ /i\ b I/ gLo Lq :

Planned Day Care Maternity

J) Type of Admission / Emergency
k) if Matemtty

1) Date of EXlivery (ii) Grwlda Status

I) Status at the tIme of discharge DIscharge to another hOspItal Deceased

m) Total Claimed Amount

Section C - Details of Ailment Diagnosed (Primary)

,Md APtada \
Heb.
a) (1) PHmaryDiagnosls : ICD IOCode;
(„) Add,ti,,,I Dbg.„i, , ICD lo Cod, , = LGB
(„) Co-morbtdrties ; ICD 10 Code :
f4 Description
a

(„) Co-m,rbid?ties , ICD 10Code: : : T I Description

b) (i) Procedure 1 : ICD 10 PCS Description

(iI) Procedure 2 : ICD 10 PCS Description

(IiI) Procedure 3 : ICD 10 PCS Description

(iv) Details of Procedure

c) Present ailment is a complication of PED :

Yes No

If yes. specify details

r–Hl r
d) Pre-authorization obtained : 1 Yes [ : No

,) P„.„rth,,nan,n „„ :i i : - JF[I : I:L

f ) if authorIzation by network hospItal not obtained. gin reason

( Health Insurance I.Imited

RegIstered Office: 5th Floor, 19Chawla House,Nehru PlaccJJcw Delhi.11(X)19 CorrespondenoeOffiae: Mpul Tech Square, Town C, 3rd Fknr, Golf Course Road, Sectorlt3,
(iuru8ram-122tXB (Haryana) Website: www carcinsurance.com crN: U66€X>ODL2007PLC161503 IRDAI Registration No. - 148 PAge
g) HospitaIIzation dueto Injury : Yes No

(i) If>es.giw cause , Selfir,nicted Road T,amc A,dde„t t S.bgt,nce Ab.se/Alcohol Consumption

(ii) if lnjury due to Substance abuse/Alcohol consumption. Test conducted to establish this : Yes No
(if yes. attach reports)
pH-
(iii) if Medico Legal : Yes No

(iv) Reported to Police : Yes No

(V) FIRNO. ; L j Tr
(vi) if not reported to Police, give reason

Section D - Claim Documents Submitted - Checklist

(1) Dub signed Claim Form (ix) Investigation Report

(iI) Original Pre-authorization request (x) CT/ MRI/ USG/HPE inwaigation reports

(iii) Copy of Pre-authorization approval letter (xi) Doctor’s reference slip for investigation

(iv) Copy of photo ID card of patient verified by hospItal (xii) ECG

(v) Hospital Discharge Summary (xiii) Pharmacy Bills

(vi) Operation Theatre notes (xiv) MLC report & Police FIR

(vii) Hospital Main Bill (xv) Original death summary from hospttaJ where applicable:

(ViiI) Hospital Break-up Bill (xvi) Any other. please specify

Section E . Additional Details in case of Non.Network Hospital (Only HIt in case of non.network hospital)
;) A„~„.„„H.@~ ; F l;iiktltAILdigi’a M£Oi6iki+MifbItII
S.V. Road, S4ntbcruz [Whs©,
[ MumbaiF 400 054. i j

City I Re& t+d?qUI$t

State Pin Code

b) Contact No.

c) RegIstratIon No. wah State Code

d) Hospital PAN ,) N,.db„p,d,.tb,d„ ZOO

f) Facilitiesavailableinthe hospital oq/\
OT:DC_b1
Cic Il Gt
No (ii) ICU : 'J' Yes No

(iii) Others

Section F - Declaration by the Hospital

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief.
statement. suppressionor concealment of any material facts. our right to claim under this claim shall be forfetted,

Date : / I i I/ i Signature & Seal of the HospRatAuthor

Place

Care Health Insurance Limited

Rcgrstend Office: Sth Floor, 19 Chawla House,Nehru Place,New Delhi-1 kX)19 Correspondence Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Roadv Sectoraj3
(;urugranl-12200'3 (Haryana) Website: www.caKinsurance.comCIN: U66000DL2007PLC161s03IRDAI Registration No. - 148 Page
 Consent Letter

Date

To

The Medical SuDrintendent

SLAy? (:it ! ax PV
OID iC mg PvT CTr9

Dear Sir,

Re : Authorization in favour of M/s Care Health Insurance Limited and its authorized agents.

t have undergone treatment for

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hereby authorise M/s Care Health Insurance Limited and/or its authorised representatIve to seek any medical information / records from you Or from the
Pledlcal PractItionerswho has attended on me in connection wIth the above ailment.

have no objection in case they seek such information/records in whatsoever regards

Thanking You
Y

X
(SIgnature of the Claimant)
Address of the Insured

A Go,1 (_ guttOtaL-

T ;r=:\::Fi&b
=J +/ F nS I

( llcalth I 'anrr I.imited

Rcgistcrcd OfFice: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 CorrespondenceOffice: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector+3
Gurugram-122009 (Haryana) Website: www.carcinsurance.com CIN: U66000DL2007PLC161503 IRDAI Registration No. - 148
 FOR\I ’C'

Certificate of Registration under Section 5 of Maharashtra (Bombay)

NJrsing Homes Registration Act, 1949. ' '
Renewed

This is to certify that DR. HIREN . AMBEGAOKAR(CEO)have been RegIstered under the
Bomba,' NursIng Homes Reclstrattu11 Act . 1949 . In respect ot SURYA CHILDRENS MEDICARE PVT
LTD. and has been authorlzea to carry on the said NursIng Home

Reglstrat,on No. 761411564

Date of RegIstratIon 24.03.2006

\Vard HW

Race ISt-5thtlr,, MANGAL ASHIRWAD,

AND 1 ST BASMENT. GRD FL
1 ST TO 4TH FLOOR . V FORTUNE MALL

JUNCTI

S.v.ROAD AND DATTRAY ROAD

SANTACRUZ (VV).MUMBAI-400054
BuIlding UtD HW 1202260050000

Total Number of Beds 200

Date ot Issue of CertIficate 18.03.2023

ThIS Certltlcate of RegistratIon shall be vaIId up to 31 st March 2026

The Money collected for NursIng Home IS Rs. 600.00 /- dated 18.03.2023. ReceIpt No
71 :642867

DIsclaImer ThIS is computer generated copy. doesn't require SIgnature

TTTr) r port . CIf , F . , 1 , 1p 1