Transcription of CLAIM FORM - mediassistindia.net
1 Dots (.)OrDashes(-)Date:SignatureoftheClaiman tPleasesendthisclaimformdulycompletedwit hallenclosuresto:MEDIASSISTINDIAPRIVATEL TD.,#49, ShilpaVidya Buildings,1stMain,SarakkiIndustrialLayou t, , :26584811 Fax:26538793 )Nameb)Relationshipc)Aged)Addresse)Phone Nof)MobileNog)E-mailAddress,ifanyAilment /Disease/InjuryDateofInjurysustained/dis easedetectedIfInjury,narrationhowitoccur redNameoftheHospitalwheretreatedNameofth etreatingDoctorQualificationRegistration NoAdmissionDate:Time:DischargeDate: (withoutbreak)Haveyoubeencoveredwithanyo therMediclaim/HealthInsurance?YesNoIf Yes pleaseattachaphotocopyofthePolicyHaveyou preferredanyclaimforthesameailmentearlie r?YesNoIf Yes ,ClaimNoStatus:Settled/DeniedIftheClaimi sforDomiciliaryhospitalisation,pleaseind icateDateofCommencementoftreatmentDateof completionoftreatmentNameofthetreatingDo ctorQualificationAddressoftheDoctorReaso nfornothospitalizingpatientIhaveincurred thefollowingexpensesforthetreatmentofthe disease/ailment/injurydetailedoverleaf:I nsupportoftheaboveclaim,Isubmitthefollow ingdocuments: orxeroxcopiesofDischargeSummary/Prescrip tions& currentaswellaspreviousIherebydeclaretha ttheinformationfurnishedinthisClaimFormi strue&correcttothebestofmyknowledge& ,suppressionorconcealmentofanymaterialfa ct.
2 SignatureoftheClaimantClaimformDulySigne dYesNoPre-hospitalisationBillsNoYesNoCop yofClaimIntimationYesNoPost-hospitalisat ionBillsNoYesNoHospitalDischargeSummaryY esNoHospitalPaymentReceiptYesNoSurgeon sCertificate,ifanyYesNoInvestigationRepo rtsYesNoSurgery/ConsultationBillsYesNoDo ctor sReferenceforInvestignYesNoHospitalMainB illYesNoMRIYesNoHospitalBreak-upBillYesN oCTScanYesNoDoctor sPrescriptionsYesNoECGYesNoPharmacyBills YesNoUSGScanYesNoAnyother( ):TobefilledbytheClaimantMediAssistUseOn lyBillNoDateIssuedbyTowardsAmountDisallo wedReasonMEDIASSISTINDIAPRIVATELTD.,#49, ShilpaVidya Buildings,1stMain,SarakkiIndustrialLayou t, , :26584811 Fax:26538793 TollFree:18004259449 MEDICALCERTIFICATETOBEFILLEDINBYTHEDOCTO RTREATINGTHEPATIENTH ospitalisation)these?durationoftheailmen t/sCongenitalinnature?forthepresentailme nt/injurychildrenexcludingthenewbornhosp ital(includingICU)ofitsown?roundtheclock ?Date:SignatureoftheDoctorwithSeal1 NameofthePatientAgeYrs2 HospitalistionPeriodDateofAdmnDateofDisc harge3 Diagnosis4 Dateoffirstconsultation(Priorto5 Presentingcomplaintsonadmission6 Sincewhenwasthepatientsufferingfrom7 PasthistoryofthePatient,ifany,with8 Whetherthepresentailmentisacomplicationo fanypre-existingailment?
3 YesNo9If Yes ,pleasespecifytheDiseaseorcomplicationof anyprevioussurgerydone&thedetailsthereof 10 WhethertheDisease/Defect/Disorderis11 NatureofTreatmentgivenorSurgeryperformed 12 IftheclaimisforMaternity,numberofliving1 3 WhethertheHospitalisregisteredwithLocalA uthorities?If Yes pleasefurnishRegistrationNo14 NumberofIn-patientbedsinthe15 WhetherthehospitalhasfullyequippedOT16 Whetherqualifiednursesemployed17 WhetherunderthesupervisionofaRegisteredM edicalPractitionerroundtheclock?ToDearSi r/s,Re: ,Ihaveundergonetreatmentforfromtoinyourh ospitalunderInpatientNo:. ,whoaremyTPAfortheMediclaimpolicyIhave, ,Yours faithfully,(Signatureof the Claimant)Date:AddressoftheInsured.
