REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH

REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE

POLICY PART - C (Revised)

(TO BE FILLED IN BLOCK LETTERS)

DETAILS OF THE THIRD PARTY ADMINISTRATOR/ INSURER/ HOSPITAL

Name of TPA / lnsurance company:

Toll free phone number:

Toll free fax:

Name of Hospital:

iii.

ii.

i. Address

Rohini id

e-mail id

TO BE FILLED BY INSURED/PATIENT

Name of the Patient :

Contact number:

Gender:

Age:

lnsured Card ID number:

Policy number / Name of Corporate:

Contact number of attending Relative:

Employee ID:

Date of Birth:

Currently do you have any other mediclaim / health insurance:J.

Male Female Third Gender

(Years) / (Month)

(DD/MM/YYYY)

Yes

Company Name:i.

Give Detailsii.

Contact number, if any:

Current Address of lnsured patient:

Name of the Family Physician:

Do you have a family Physician:

O. Occupation of Insured patient:

VIDAL HEALTH INSURANCE TPA PRIVATE LTD.

Yes No

(PLEASE COMPLETE DECLARATION OF THIS FORM)

Page 1 of 4

TO BE FILLED BY TREATING DOCTOR/HOSPITAL

Relevant Critical Findings:D.

Contact number:

Nature of Illness / Disease with presenting complaint:

Name of the treating Doctor:

Provisional diagnosis:

Date of First consultation:

ii.

Duration of the present ailment:

Past history of present ailment, if any

Days

ICD 10 code

Yes

Medical Management

ii. Surgical Management

Proposed line of treatment:

iv. Investigation

Non-allopathic treatmentv.

( )

If investigation and / or Medical Management, provide detailsH.

Route of Drug Administration :

I. lf surgical, name of surgery

J. If other treatment, provide details

ln case of accidentL.

ICD l0 PCS code

Is it RTA:

ii.

Date of lnjury:

iii.

Report to Police

iv.

FIR NO:

Injury / Disease caused due to substance abuse / alcohol consumption

Test conducted to establish this (if yes, attach report)

vi.

How did injury occurK.

In case of MaternityM.

Yes

Yes No

(DD/MM/YYYY)

expected date of Delivery

(DD/MM/YYYY)

ii. Intensive care ( )

(DD/MM/YYYY)

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DETAILS OF PATIENT ADMITTED

Mandatory Past History of any chronic illness

Is this an emergency / planned hospitalization event:

Date of admission

Time of admission

(DD/MM/YYYY)

(HH:MM)

Emergency Planned

if yes (since __ /____)(month/year)

iii.

Heart disease

vi.

Diabetes

Hyperlipidemias

Asthma/COPD/Bronchitis

ii.

iv.

Hypertension

Osteoarthritis

viii.

Cancer

Alcohol/Drug abuse

vii.

iX. Any HIV/ or STD Related ailment

X. Any other ailment, give details

Room Type

Expected cost of investigation + diagnostic

Per day room rent+nursing and service charges+ patients diet

All-inclusive package charges if any applicable

Other hospital expenses if any

OT charges

Medicines + Consumables + Cost of Implants (if applicable please specify)

Professional fees Surgeon + Anesthetist Fees + consultation Charges

Expected number of Days / stay in hospital

Sum Total expected cost of hospitalization

ICU charges

Days in ICU

Days

Qualification:

We confirm having read understood and agreed to the Declarations of this form

DECLARATION

Registration number with State code

(Please read very carefully)

Name of the treating doctor

Hospital Seal

(Must include Hospital ID)

Patient / lnsured Name and Sign

Page 3 of 4

a) Patient’s / Insured’s Name:

DECLARATION BY THE PATIENT / REPRESENTATIVE

c) Patient’s / Insured’s Signature:

HOSPITAL DECLARATION

b) Contact Number:

Hospital Seal

Doctor’s Signature

email-Id (optional)

a. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to

hospitalization.

b. All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to

TPA / lnsurance Company within 7 days of the patient's discharge.

c. We agree that TPA / Insurance Company will not be Iiable to make the payment in the event of any discrepancy between

the facts in this form and discharge summary or other documents.

d. The patient declaration has been signed by the patient or by his representative in our presence.

e We agree to provide clarifications for the queries raised regarding this hospitalization and we take responsibility

the sole for any delay in offering clarifications.

f. We will abide by the terms and conditions agreed in the MOU.

g. We confirm that no additional amount would be collected from the insured in excess of Agreed Package Rates except

costs towards non-admissible amounts (including additional charges due to opting higher room rent than

eligibility / choosing separate line of treatment which is not envisaged / considered in package).

h. We confirm that no recoveries would be made from the deposit amount collected from the lnsured except for costs

towards non-admissible amounts (including additional charges due to opting higher room rent than eligibility / choosing

separate line of treatment which is not envisaged / considered in package).

i . In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed Package Rates,

the authorized TPA / Insurance Company reserves the right to recover the same from us (the Network Provider) and / or

take necessary action , as provided under the MoU or applicable laws.

a. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer / TPA after the

discharge. I agree to sign on the Final Bill & the Discharge Summary, before my discharge.

b. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / TPA is not liable to settle

the hospital bill, I undertake to settle the bill as per the terms and conditions of the policy.

c. All non-medical expenses and expenses not relevant to current hospitalization and the amount over & above the limit

authorized by the Insurer / T.P.A. not governed by the terms and conditions of the policy will be paid by me.

d. 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 / T.P.A.

e. I agree and understand that T.P.A. is in no way warranting the service of the hospital & that the Insurer / TPA is no way

guaranteeing that the services provided by the hospital will be of a particular quality or standard.

f. 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 claim, my right to claim reimbursement of

the said expenses shall be absolutely forfeited.

g. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the

insurer / TPA.

h. "I/We authorize Insurance Company / TPA to contact me/us through mobile/email for any update on this claim"

Date: Time:

Time:Date:

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