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Investigation Format

The document appears to be an investigation report form for a new health insurance scheme in Tamil Nadu that collects details about a patient's claim such as diagnosis, treatment received, investigations done, and information to verify the authenticity of the claim like signatures and documentation. The form collects information from the hospital, treating doctor, patient, laboratory, pharmacy and investigator to assess the claim.

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Vinoth Paul
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5K views2 pages

Investigation Format

The document appears to be an investigation report form for a new health insurance scheme in Tamil Nadu that collects details about a patient's claim such as diagnosis, treatment received, investigations done, and information to verify the authenticity of the claim like signatures and documentation. The form collects information from the hospital, treating doctor, patient, laboratory, pharmacy and investigator to assess the claim.

Uploaded by

Vinoth Paul
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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TAMIL NADU NEW HEALTH INSURANCE SCHEME

INVESTIGATION REPORT
Type of Investigation Preauth / Claims
Investigation Triggered by
Medical Team
Provider Team / FACC Team
Claims details
CCN NO
Name of the Patient
Age / Sex
Name of the Hospital
Diagnosis
Mode of Investigations
Hospital Visit Yes / No
Patient Visit Yes / No
Pharmacy Visit Yes / No
Lab Visit Yes / No
Residence Visit Yes / No
Investigator Details
Name of Investigator
Date of Investigation
Time of Investigation
Hospital Details
Name
Address
Details
Type of Hospital General / Single Speciality / Multispeciality
Treating Doctor Details
Name
Qualification
Registration No.
Mobile No.
Patient Details
Name
Age / Sex Occupation :
Address
IPD NO Admitted / Discharged

Diagnosis
Date & Time of Admission
Date & Time of Discharge
Photo ID Proof Verified / Collected
Illness Details
Type of Illness Acute / Chronic / Accidental
Duration of Illness
Presenting Symptoms at the
time of admission

Any Past H/o


Accidental
MLC / FIR
Any Discrepency Noted in
Actual & Documents sent
Treatment Details
Line of Treatment Conservative / Surgical / Medical

Conservative / Medical
Management
Specify Others

Surgery / Procedure
Type of Anaesthesia General / Local / Spinal
Investigations Details
Blood
Urine
Bio chemistry
Radiological Investigations
Specialised Investigations
Investigations done
Xray / USG / CT Scan / MRI
Relevant
Irrelevant
Laboratory Details
Name of the Lab
In House / Outsourced
Pharmacy Details
Name of the Pharmacy
Inhouse / Outsourced

Hospital Sign & Seal

Signature of the patient /


relatives

Signature of the Investigator

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