Transcription of CLAIM FORM - E-Meditek
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CLAIM FORM - E-Meditek
DETAILS OF HOSPITALa) Name of the hospital:b) Hospital ID:c) Type of Hospital:NetworkNon Network(if non network fill section E)d) Name of the treating doctor:SURNAMEFIRSTNAMEMIDDLENAMEe) Qualification:f) Registration No. with State Code:g) Phone OF THE PATIENT ADMITTEDa) Name of the Patient:SURNAMEFIRSTNAMEMIDDLENAMEb) IP Registration Number:c) Gender:MaleFemaled) Age: YearsYYMonthsM Me) Date of Birth:DDM MYYf) Date of Admission: DDM MYYg) Time:HHM Mh) Date of Discharge:DDM MYYi) TimeHHM Mj) Type of Admission: EmergencyPlannedDay Carek) if Maternity i.
Use dd-mm-yy format Use hh-mm format GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital) SECTION A- …
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