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PLEASE FAX / SCAN PAGE 1 ON LY

REQUEST FOR CASHLESS HOSPI TALIS ATION FOR MEDICAL INSURANCE POLICY
Medi Assist
Name of the Hospital

Hospital Location Hospital ID

Hospital Fax No. Hospital Phone No

DE TAILS OF THIRD PARTY ADMINISTR ATOR ( To be Filled in block letters )

a) Name of TPA / Insurance company: Medi Assist India TPA Pvt

, Ltd b) Toll Free Phone Number: 1800 425 9449 c) Toll Free F A X Number: 1800 425 9559
To Be ed in By Insured / Patient

a) Name of the Patient: S U R N A M E F I R S T N A M E M I D D L E N A M E

b) Gender: Male Female c) Age: Year s Y Y Months M M d) Date of birth D D M M Y Y Y Y

e) Contact number: f) Insured Card ID Number:

g) Policy number/Name of corporate: h) Employee ID:

h) Currently do you have any other Mediclaim/HealthInsurance: Yes No Company Name

Give details:

i) Do you have a family physician Yes No j) Name of the family physician

k) Contact number, if any: (PLEASE COMPLETE DECLAR ATION ON THE REVERSE SIDE OF THIS FORM)
TO BE FILLED BY THE TREATING DOCTOR / HOSPI TAL

a) Name of the treating doctor : b) Contact Number:

c) Name of ILLNESS / Disease d) Relevant clinical ndings:

with presenting complaints

e) Duration of the present ailment: D ays I) Date of rst consultat io n D ii. Past history of
D M M Y Y
present
f) Provisional diagnosis: ailmentif any:

iii. ICD 10 Code:

g) Proposed line of treatment: Medical Management Surgical Management Intensivecare Investigation Non allopathic treatment

h) If investigation / or Medical i.Route of drug administration:

Management provide
details:

i) If Surgical, name of surgery:

i. ICD 10 PCS Code:

j) If other treatments provide k) How did injury occur:

details :

l) In case of accident: I. Is it RTA: Yes No ii. Date of injury: M M Y Y Y Y iii. Reported to Police Yes No iv. FIR No.

v. Injury/ Disease caused due to substance abuse / alcohol consumption: Yes No vi. Test conducted to establish this: Yes No (If Yes attachreports)

m) In case of Maternity: G P L A Date of Delivery / LMP : D D M M Y Y

Details of the patient admited Mandatory:
a) Date of admission: D D M M Y Y b) Time H H M M Past History of any chronicillness If yes, since (Month/ year)

Diabetes M M Y Y
c) Is this an emergency/a planned hospitalization event?: Emergency Planned
Heart Disease M M Y Y

d) Expected no. of days stay in hospital: Days e) Room Type M M Y Y

Hypertension
f) Per Day Room Rent + Nursing & Service charges + Patients Diet: Rs.
Hyperlipidemias M M Y Y

g) Expected cost for investigation + diagnostics: Rs. M M Y Y

Osteoarthritis

h) ICU Charges: Rs. Asthma/ COPD / Bronchitis M M Y Y

i) OT Charges: Rs. Cancer M M Y Y

M M Y Y
j) Professional fees Surgeon+ Anesthetist Fees + Consultation Charges: Rs. Alcohol or drug abuse
M M Y Y
k) Medicines + Consumables Cost of Implants (if applicable please Rs. Any HIV or STD / Related ailments
specify). Other hospital expenses if any:
Any other Ailment give details:
I) All inclusive package charges if any applicable: Rs.

m) Sum Total expected cost of hospitalization Rs.

(PLEASE READ VERY CAREFUL LY)

DECLAR ATION

We con rm having read understood and agreed to the Declaration on the reverse of this form

a) Name of the treating doctor: S U R N A M E F I R S T N A M E M I D D L E N A M E

b) Quali ation: c) Registration No. with State Code:

Hospital Seal (Must include Hospital ID) Patient/ InsuredName & Signature:
IMPORTANT: PLEASE TURN OVER
 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. I agree to sign on the Final Bill & the Discharge Summary,
before my discharge.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

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

a) Patients / Insureds Name:

b) Contact Number: c) Patients / Insureds Signature:

HOSPITAL DECLARATION

1. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaing to hospitalization

2. All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent TPA / Insurance Company within 7 days of the patients discharge.

2. All non medical expenses, OR expenses not relevant to hospitalization or illness, OR expenses disallowed in the Authorization Letter of the TPA / Insurance Co. OR arising out of incorrect
information in the pre-authorisation form will be collected from the patient.

4. WE AGREE THAT TPA / INSURANCE COMPANY WILL NOT BE LIABLE TO MAKE THE PAYMENT IN THE EVENT OF ANY DISCREPANCY BETWEEN THE FACTS IN THIS FORM
AND DISCHARGE SUMMARY or other documents.

5. The patient declaration has been signed by the patient or by his represent in our presence.

6. We agree provide clarification for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications.

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

Hospital Seal Doctors Signature

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed Discharge Summary and all Bills from the hospital.

2. Cash Memos from the Hospitals / Chemists supported by proper prescription.

3. Receipts and Pathological Test Reports from Pathologists, Supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests.

4. Surgeons Certificate stating nature of Operation performed and Surgeons Bill and Receipt.

5. Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured.