1 : : : a) Name of the Patientb) GenderYYMMDDMMYYYYe) Contact numberf) ID numberg) Contact Number of attending relativej) Currently do you have any other Mediclaim/Health insuranceYesNo Company Namek) Do you have a family physicianYesNom) Contact number, If anya) Name of the treating doctorb) Contact numbere) Duration of the Present ailmentDAYSi. Date of first consultationDDMMYYg) Proposed line of treatmentMedical ManagementSurgical ManagementIntensive careInvestigationNon allopathic treatmentii) Route of drug administrationOralParenterali) If Surgical, name of surgeryi. ICD 10 PCS Code PLEASE FAX/SCAN PAGE 1 ONLY REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICAL INSURANCE POLICYTO BE FILLED BY THE INSURED / PATIENT0124 - 4466677 DETAILS OF THE THIRD PARTY ADMINISTRATOR(To be filled in block letters)a) Name of TPAb) Toll free phone number d) FAX NoGive detailsl) Name of the family physician( PLEASE COMPLETE DECLARATION ON THE REVERSE SIDE OF THIS FORM)f) Provisional diagnosisi.
2 ICD 10 Codeii. Past history of present ailment if anyh) If Investigation & / or Medical Management provide details MaleFemaleE-Meditek Insurance TPA Limited1800 102 3242 c) Hot Line : 0124 - 4980555 Monthsd) Date of Birthc) Age : Yearsc) Nature of ILLNESS/Disease with presenting complaintsd) Relevant clinical findingsh) Policy number/Name of corporatei) Employee IDTO BE FILLED BY THE TREATING DOCTOR/HOSPITALi) If Surgical, name of surgeryi. ICD 10 PCS Codeii. Type of AnaesthesiaLocalGASpinall) In case of accidenti. Is it RTAYesNoii. Date of InjuryDDMMYYiii. Reported to Policeiv. FIR Injury/Disease caused due to substance abuse / alcohol comsumptionYesNovi. Test conducted to establish thisYesNo(If Yes attach reports)m) In case of MaternityGPLADate of DeliveryDDMMYYD etails of the patient admitteda) Date of admissionDDMMYYb) TimeHH:MMc) Is this an emergency / a planned hospitalization event ?
3 EmergencyPlannedDiabetesMMYYd) Expected no. of days stay in hospitalDayse) Room TypeHeart DiseaseMMYYH ypertensionMMYYH yperlipidemiasMMYYO steoarthritisMMYYh) ICU ChargesAsthma/COPD/BronchitisMMYYi ) OT ChargesCancerMMYYA lcohol or drug abuseMMYYAny HIV or STD / Related ailmentsMMYYAny other Ailment give details( PLEASE READ VERY CAREFULLY)We confirm having read understood and agreed to the Declarations on the reverse on this forma) Name of the treating doctorb) Qualification _____c) Registration No. with State codeName of the Hospital / Nursing HomeHospital City _____e-mail IDFax No.` ) All inclusive package charges if any applicableg) Expected cost for investigation + diagnosticsMandatory: Past History of any chronic illnessIf yes, since(month / year)f) Per Day Room Rent + Nursing & Service Charges + Patients ) Medicines + Consumables + Cost of Implants (if applicable PLEASE specity), Other hospital expenses if anyj) Professional fees Surgeon + Anesthetist Fees + consultation ) If other treatment Provide detailsk) How did injury occurTreating Doctor Signaturem) Sum Total expected cost of / Mobile (IMPORTANT PLEASE TURN OVER)Hospital Seal (Must include Hospital ID)Patient / Insured Name & SignatureDECLARATION BY THE PATIENT / REPRESENTATIVEa) Patient's / Insured's Nameb) Contact numberc) Patient's / Insured's SignatureHOSPITAL DECLARATION1.
4 We have no objection to E-Meditek Insurance TPA Limited/Insurance Company official verifying documents pertaining to hospitalization4. I hereby declare to abide by the terms and conditions of the policy and if at any facts disclosed by me are found to be false or incorrect I forfeit my claim and agree to indemnify the insurer / E-Meditek Insurance TPA LimitedPAGE 2 : NOT TO BE FAXED/SCANNED3. All non-medical expenses and expenses not relevant to current hospitalization and the amount over & above the limit authorized by the Insurer/ E-Meditek Insurance TPA Limited not governed by the terms and conditions of the policy will be paid by Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / E-Meditek Insurance TPA Limited is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of the I agree and understand that E-Meditek Insurance TPA Limited is in no way warranting the service of the hospital & that the Insurer/ E-Meditek Insurance TPA Limited is no way guaranteeing that the services provided by the hospital will be of a particular quality or I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, Suppression or concealment with respect to the 7.
5 I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the insurer/ E-Meditek Insurance TPA All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent E-Meditek Insurance TPA Limited / Insurance Company within 7 days of the patient s All non medical expenses, OR expenses not relevant to hospitalization or illness, OR expenses disallowed in the Authorization Letter of the E-Meditek (TPA) Services Limited/ Insurance Co. OR arising out of incorrect information in the pre-authorisation form will be collected from the WE AGREE THAT E-Meditek Insurance TPA Limited / INSURANCE COMPANY WILL NOT BE LIABLE TO MAKE THE PAYMENT IN THE EVENT OF ANY DISCREPANCY1. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/E-Meditek Insurance TPA Limited after the discharge.
6 I agree to sign on the Final Bill & the Discharge Summary, before my The patient declaration has been signed by the patient or by his represent in our We agree provide clarification for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering We will abide by the terms and conditions agreed in the SealDoctor's SignatureDOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM1. Detailed Discharge Summary and all Bills from the Cash Memos from the Hospitals / Chemists supported by proper Receipts and Pathological Test Reports from Pathologists, Supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Surgeon s Certificate stating nature of Operation performed and Surgeon s Bill and Certificates from attending Medical Practitioner / Surgeon that the patient is fully WE AGREE THAT E-Meditek Insurance TPA Limited / INSURANCE COMPANY WILL NOT BE LIABLE TO MAKE THE PAYMENT IN THE EVENT OF ANY DISCREPANCY BETWEEN THE FACTS IN THIS FORM