Health Claim Form

Part B

1. To be filled in by the hospital.

2. The issue of this Form is not to be taken as an admission of liability.
3. Please include the original pre-authorization request form in lieu of PART A.
4. To be filled in block letters.

Section A - Details of Hospital

a) Name of the Hospital :

b) Hospital ID :
c) Type of Hospital : Network Non-network (if non-network fill section E)
d) Name of the treating doctor :
(Surname) (First Name) (Middle Name)

e) Qualification :
f) Registration No. with State Code :
g) Contact No. :

Section B - Details of the Patient Admitted

a) Name of the Patient:
(Surname) (First Name) (Middle Name)

b) IP Registration No. :
c) Gender : M F d) Age : / (YY/MM) e) Date of Birth : / /
f) Date of Admission : / / (DD/MM/YYYY) g) Time of Admission : : (HH:MM)

h) Date of Discharge : / / (DD/MM/YYYY) i) Time of Discharge : : (HH:MM)

j) Type of Admission : Emergency Planned Day Care Maternity

k) If Maternity,
(i) Date of Delivery : / / (DD/MM/YYYY) (ii) Gravida Status : ________________________________
l) Status at the time of discharge : Discharge to home Discharge to another hospital Deceased
m) Total Claimed Amount :

Section C - Details of Ailment Diagnosed (Primary)

a) (i) Primary Diagnosis : ICD 10 Code : Description : ________________________________________________________
(ii) Additional Diagnosis : ICD 10 Code : Description : ________________________________________________________
(iii) Co-morbidities : ICD 10 Code : Description : ________________________________________________________
(iv) Co-morbidities : ICD 10 Code : 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 : _________________________________________________________________________________________

d) Pre-authorization obtained : Yes No

e) Pre-authorization no. :

f) If authorization by network hospital not obtained, give reason : ______________________________________________________________________

__________________________________________________________________________________________________________________________

Care Health Insurance Limited

Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Correspondence Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43,
Gurugram-122009 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 IRDAI Registration No. - 148
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g) Hospitalization due to Injury : Yes No

(i) If yes, give cause : Self inflicted Road Traffic Accident Substance Abuse/Alcohol Consumption

(ii) If Injury due to Substance abuse/Alcohol consumption, Test conducted to establish this : Yes No
(If yes, attach reports)

(iii) If Medico Legal : Yes No

(iv) Reported to Police : Yes No

(v) FIR No. :

(vi) If not reported to Police, give reason : ______________________________________________________________________________

Section D - Claim Documents Submitted - Checklist

(I) Duly signed Claim Form : (ix) Investigation Report :

(ii) Original Pre-authorization request : (x) CT/ MRI/ USG /HPE investigation 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 hospital where applicable:

(viii) Hospital Break-up Bill : (xvi) Any other, please specify_____________________ :

Section E - Additional Details in case of Non-Network Hospital (Only fill in case of non-network hospital)

a) Address of the Hospital :

City :
State : Pin Code :
b) Contact No. : -
c) Registration No. with State Code :
d) Hospital PAN : e) No. of inpatient beds :
f) Facilities available in the hospital : (i) OT : Yes No (ii) ICU : Yes No
(iii) Others : _____________________________________________________________________________________________________________

Section F - Declaration by the Hospital

(Please read very carefully)
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue
statement, suppression or concealment of any material facts, our right to claim under this claim shall be forfeited.

Date : / / (DD/MM/YYYY) Signature & Seal of the Hospital Authority : _________________

Place : _____________________________________________

Care Health Insurance Limited

Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Correspondence Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43,
Gurugram-122009 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 IRDAI Registration No. - 148
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Guidance For Filling Claim Form- Part B (To be filled in by the hospital)
Data Element Description Format
Section A - Details of Hospital
a) Name of Hospital Enter the name of hospital Name of hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital Indicate whether In network or non-network hospital Tick the right option
d) Name of treating doctor Name of treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor along As allocated by the Medical Council of India
with the state Code
g) Contact No. Enter the phone number of doctor Include STD code with telephone number
Section B - Details of Patient Admitted
a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
d) Age Enter age of the patient Number of years and months
e) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
f) Date of admission Enter date of admission Use dd-mm-yy format
g) Time Enter time of admission Use hh:mm format
h) Date of discharge Enter date of discharge Use dd-mm-yy format
i) Time Enter time of discharge Use hh:mm format
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
m) Total claimed amount Indicate the total claimed amount In rupees (Do not enter paise values)
Section C - Details of Ailment Diagnosed (Primary)
a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description of the primary Standard Format and Open text
Diagnosis
Additional Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
additional Diagnosis
Co-morbidities Enter the ICD 10 Code and description of the Standard Format and Open text
co-morbidities
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first Standard Format and Open text
procedure
Procedure 2 Enter the ICD 10 PCS and description of the second Standard Format and Open text
procedure
Procedure 3 Enter the ICD 10 PCS and description of the third Standard Format and Open text
procedure
Details of Procedure Enter the details of the procedure Open text
c) PED Indicate whether present ailment is a combination of PED Tick Yes or No
If yes, specify details Enter the details of PED Open text
d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
e) Pre-authorization Number Enter pre-authorization number As allotted by TPA
f) If authorization by network hospital not obtained, Enter reason for not obtaining pre-authorization number Open text
give reason
g) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol consumption, Indicate whether test conducted Tick Yes or No
test conducted to establish this
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported To Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authorities
If not reported to police, give reason Enter reason for not reporting to police Open text
Section D - Claims Document Submitted Checklist
Indicate which supporting documents are submitted

Care Health Insurance Limited

Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Correspondence Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43,
Gurugram-122009 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 IRDAI Registration No. - 148
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 Data Element Description Format
Section E - Additional Details in case of Non-Network Hospital
a) Address Enter the full postal address Include Street, City and Pin Code
b) Contact No. Enter the phone number of hospital Include STD code with telephone number
c) Registration No. with State Code Enter the registration number of the doctor along As allocated by the Medical Council of India
with the state Code
d) Hospital PAN Enter the permanent account number As allotted by the Income Tax department
e) Number of Inpatient beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify
Section F - Declaration by the Hospital
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp

Care Health Insurance Limited

Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Correspondence Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43,
Gurugram-122009 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 IRDAI Registration No. - 148
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 Consent Letter

Date

To,
The Medical Suprintendent
_________________________________
_________________________________
_________________________________

Dear Sir,

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

I have undergone treatment for

_____________________________________________________________________________________________________________________

___________________from _____________________to _______________in your hospital under Inpatient No_________.

I hereby authorise M/s Care Health Insurance Limited and/or its authorised representative to seek any medical information / records from you or from the
Medical Practitioners who has attended on me in connection with the above ailment.

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

Thanking You,
Yours Faithfully

(Signature of the Claimant)

Address of the Insured -

Care Health Insurance Limited

Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Correspondence Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43,
Gurugram-122009 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 IRDAI Registration No. - 148
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