NATIONAL PRIVATE PATIENT HOSPITAL CLAIM …

1 NATIONAL PRIVATE PATIENT HOSPITAL CLAIM FORM1. PATIENT / FUND MEMBERSHIP DETAILS (Please print and insert ticks ( ) in boxes)2. DECLARATION CONCERNING CLAIM (The accurate answers to these questions are an essential part of this CLAIM )3. HOSPITAL ACCOMMODATION DETAILS (To be completed by HOSPITAL : please see overleaf for codes.) PRIVATE Health FundHospitalHospitalHospitalProvider NumberRecord NumberAdmission Date: / /Separation Date: / /Admission TypeAmountCodeCodeFromToCodeClaimedCodeC hargedOther:Other:Other:Other:Same Day patients Only (Please tick ( ) boxes below)AdmissionSeparationSame DayTime (24hr):Time (24hr):Band (1-4)Anaesthetic: None Local Intravenous Regional GeneralTheatre/MBS (*Principal MBS first)MBS ItemDate of ServiceAmount Charged*Time in Theatre (ALL EPISODES 24 hr)From:To:From:To:From:To.

2 Family Name of PatientMr/Mrs/Miss/MsGiven Names of PatientMembership NumberLevel of CoverRelationship ofPatient sPatient to MemberDate of Birth / / AgeFamily Name of MemberMr/Mrs/Miss/MsGiven Names of MemberResidential Addressof MemberPostcodeIs this a permanent address? Yes No EmailTelephone: Home ( )Work ( )MobileAdding a newborn child to your family membership:SexDate of Birth / /Family NameGiven NamesFull name of Admitting Medical Practitioner: PATIENT /Guardian to complete (please tick ( ) below) YesNoDo you have entitlement to CLAIM compensation or damages (including previous settlements)?

3 Have you lodged a CLAIM for compensation or damages?Did the injury or condition occur at work, going to or from work or as a result of being at work?Did the hospitalisation result from a motor vehicle accident?Did the hospitalisation result from any other type of accident?Does the PATIENT have an entitlement to free treatment under Australian Veterans legislation?Is the PATIENT a full-time student dependant over 17 years and under 25 years?If yes, name of educational institution:Date PATIENT was first aware of symptoms: / / Date PATIENT first consulted a doctor for symptoms: / /Were the financial implications of your HOSPITAL charges explained prior to admission?

4 Have you signed an Election Form to elect to be treated as a PRIVATE PATIENT ? (PUBLIC HOSPITAL patients ONLY)I hereby declare and warrant that all the above information provided in connection with this CLAIM is true and authorise the HOSPITAL , or any other authorities concerned with this hospitalisation, injury, disease or ailment, or thetreatment or diagnosis, to supply all information, including HOSPITAL Casemix Protocol information as required by theFederal Government, to the PRIVATE health fund for the purpose of providing PRIVATE health insurance in accordancewith the fund s privacy authorise my health fund to pay benefits directly to the s/Guardian s Signature:Date.

5 / /Other ServicesCodeDate of ServiceNumberAmount ChargedCertificates Attached:Please tick ( ): Acute Psych. Rehab. ICU NICU Pt. Election Same Day Certification(See Section 4 overleaf)Diagnoses / Procedures / Other DetailsDRG DRG VERSIONPRINCIPAL DIAGNOSIS ICD-10-AM*Infant/NeonateAge inUrgency ofMode ofSource ofTransfer InWeightDaysAdmissionSeparationReferralC are TypeNon-AcuteTotal Leave ICU HoursMV HoursTransfer OutLengthDaysof StaySame Day StatusMental HealthInter-HospitalUnplanned Theatre VisitProvider No. of HospitalProvider No. of HospitalLegal StatusContracted PatientDuring Episode:Transferred From:Transferred To:Yes NoAdditionalDiagnosesICD-10-AMProcedureC odes ICD-10-AM(*PrincipalProcedure first)I certify the above information is true and correct according to our records for this period of hospitalisation.

6 The HOSPITAL authorisesthe fund or its agent to inspect all records applicable to the PATIENT for the purpose of determining appropriate HOSPITAL Officer s Signature:Date:/ /Gi9533 CODES FOR CLAIM FORM ITEMS*ADMISSION CODES1 Admission Claim2 Continuation Claim3 Unplanned Re-admission within 28 Days4 Same Day5 Transfer from Another Hospital6 Other Re-admissionACCOMMODATION CODES1 Single Room2 Shared Room3 Shared Room+4 Coronary Care5 Intensive Care6 Other (eg HDU)7 Neonatal8 Nursing Home Type Patient9 Rehabilitation Program10 Psychiatric Program11 Outreach/ HOSPITAL in the Home CareDISCHARGE CODES1 Discharged2 Interim Claim3 Deceased4 On Leave5 Transfer to Another Hospital6 Early Discharge ProgramPAYMENT TYPE CODES1 Per Diem2 Case Payment3 Other_____( HOSPITAL to insert other payment type)

7 OTHER SERVICES CODES1 Labour Ward2 Theatre Fee3 Pharmaceuticals4 Nursery Fee5 Disposables6 Prostheses8 Allied Health Services7 OtherINFANT / NEONATE WEIGHTThe admission weight rounded to thenearest OF ADMISSION CODES1 Urgency status assigned emergency2 Urgency status assigned elective3 Urgency status not assigned9 Not known / not reportedMODE OF SEPARATION CODES1 Discharge / Transfer to an (other) AcuteHospital2 Discharge / Transfer to a Nursing Home3 Discharge / Transfer to an (other)Psychiatric Hospital4 Discharge / Transfer to Other Health CareAccommodation5 Statistical Discharge Type Change6 PATIENT Left against Medical Advice7 Statistical Discharge from Leave8 Died9 To Home / OtherSOURCE OF REFERRAL CODESThe facility from which the PATIENT wasreferred as follows:0 Born in Hospital1 Admitted PATIENT Transferred fromAnother Hospital2 Statistical Admission Type Change4 From Accident/Emergency5 From Community Health Service6 From Outpatients Department7 From Nursing Home8 By Outside Medical Practitioner9 OtherTRANSFER CODES TRANSFER IN ORTRANSFER OUTU Up Transfer.

8 This / the next HOSPITAL stayis expected to be more resource intensivethan the next / previous HOSPITAL stayD Down Transfer:This / the next hospitalstay is expected to be less resourceintensive than the next / previous hospitalstayL Lateral Transfer:This / the next hospitalstay is expected to be of similar resourceintensity as the next / previous hospitalstayX UnknownCARE TYPE CODESThe type of service for which the PATIENT was initially admitted:10 Acute Care20 Rehabilitation Care21 Rehabilitation Care Delivered in a Designated Unit22 Rehabilitation Care According to a Designated Program23 Rehabilitation Care is the Principal Clinical Intent30 Palliative Care31 Palliative Care Delivered in a Designated Unit32 Palliative Care According to a Designated Program33 Palliative Care is the Principal Clinical Intent40 Geriatric Evaluation and Management50 Psychogeriatric Care60 Maintenance Care70 Newborn Care80 Other Admitted PATIENT Care90 Organ Procurement - Posthumous100 HOSPITAL BoarderICU HOURSThe number of hours spent by the PATIENT

9 In one or more of thefollowing:ICU; CCU; Neonatal Intensive Care; Paediatric Intensive does not include days spent in Special Care Nurseries or HighDependency (MECHANICAL VENTILATION) HOURSThe number of hours (rounded) for which the PATIENT receivedmechanical ventilation in ICU during the DAY STATUS CODES0 PATIENT with a Valid Arrangement allowing for Overnight Stay forProcedure normally performed on a Same Day Basis. (Pleasecomplete Overnight Stay Certification)1 Same Day Patient2 Overnight PATIENT (other than type 0 above)MENTAL HEALTH LEGAL STATUS CODES1 Involuntary2 Voluntary3 Not permitted to be reported under legislative arrangements in the jurisdiction8 Not applicableINTER- HOSPITAL CONTRACTED PATIENT CODES1 Inter- HOSPITAL contracted PATIENT from public sector2 Inter- HOSPITAL contracted PATIENT from PRIVATE sector3 Other9 Not reported* Based on HOSPITAL Casemix Protocol data definitions published by the Australian Government Department of Health & DAY ONLY PROCEDURES AND OVERNIGHT STAY CERTIFICATION(PLEASE TICK ( ) BELOW)

10 DATE OF SERVICE:/ /Day Only Procedures CertificationCertificate for the purpose of paragraph (bj), Schedule 1, NATIONAL Health Act, 1953 Overnight Stay Admission CertificationCertificate for the purpose of paragraph (bj), Schedule 1, NATIONAL Health Act, 1953 Note: Overnight Certificate only required when a Band 1 or a non-band specific Type B PATIENT isadmitted as an Overnight Stay PatientI certify that this hospitalisation / overnight stay was necessary because of:The medical condition of the PATIENT named overleaf, special circumstances, specify medical condition and / or other special circumstances:Name of medical practitioner providing the professional treatment:Name of authorised HOSPITAL health professional (where applicable):[Overnight certification may be provided by a professional employed by the HOSPITAL who is suitablyqualified to do so.]