Transcription of To be Filled in b lock et rs - MediBuddy
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To be Filled in b lock et rs - MediBuddy
M I D D L E N A M E D D M M Y Y Y Y c) Is this an emergency / a planned hospi talization event?: Emergency Pl anned Heart Disease M M Y Y M M Y Y d) Expected no. of days stay in hospi tal: Days e) Room Type Hypertensionf) Per Day Room Rent + Nursing & Servic e charges + Patient Ds iet: demias M M Y Y g) Expected cost for investigation + di agnosti thriti s M M Y Y h) ICU Charges: / COPD / Bronchi ti s M M Y Y i) OT Char M M Y Y M M Y Y M M Y Y j) Professional fees Surgeon + Anesthetis t Fees + Consult ation Charges.
PAGE 2 : NOT TO BE FAXED/SCANNED DECLARATION BY THE PATIENT / REPRESENTATIVE 1. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TPA after the discharge.
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