Pre-Authorisation Form - ‘Care’

Request for Cashless Hospitalisation for Medical Insurance Policy

1. To be filled in CAPITAL LETTERS only.
2. If there is insufficient space, please provide further details on a separate sheet.
3. Please Fax/Scan Page 1 & 2 only.

Details of the Third Party Administrator

a) Name of TPA/Insurance Company :

b) Toll Free Phone No.: c) Toll Free FAX :

d) Name of Hospital :

i) Address :

ii) Rohini ID :

iii) Email ID :

To be filled by the Insured/Patient

a) Name of the Patient :
(First Name) (Middle Name) (Last Name)

b) Gender : M F Third Gender c) Age : (YY/MM) d) Date of Birth : / /

e) Contact Number : -

f) Contact Number of Attending Relative :

g) Insured Card ID Number :

h) Policy Number/Name of Corporate :

i) Employee ID :

j) Currently do you have any other Mediclaim/Health Insurance : Yes No

i) Company Name :

iI) Give Details :__________________________________________________________________________________________________________

k) Do you have a family physician : Yes No

l) Name of the family physician :

m) Contact Number, if any : -

n) Current Address of the Insured Patient :

o) Occupation of Insured Person :

To be filled by the Treating Doctor/Hospital

a) Name of the treating doctor :

b) Contact Number : -

c) Nature of Illness/Disease with presenting complaints : _____________________________________________________________________________

d) Relevant clinical findings: ____________________________________________________________________________________________________

e) Duration of the present ailment : days

i) Date of first consultation : / / (DD/MM/YYYY)

ii) Past history of present ailment if any : _______________________________________________________________________________________

f) Provisional diagnosis : ______________________________________________________________________________________________________

Ver: Jul/20

i) ICD 10 Code :

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001 (Haryana)
Page 1
Website: www.careinsurance.com E-mail: [email protected] Call us: 1800-102-4488 | 1800-102-6655
CIN: U66000DL2007PLC161503 UIN: RHIHLIP21017V052021 IRDA Registration No. - 148
g) Proposed line of treatment : Medical Management Surgical Management Intensive care Investigation

Non allopathic treatment

h) If Investigation &/or Medical Management provide details : __________________________________________________________________________

i) Route of drug administration : _____________________________________________________________________________________________

i) If Surgical, name of surgery : _________________________________________________________________________________________________

i) ICD 10 PCS Code :

j) If other treatments provide details : ___________________________________________________________________________________________

k) How did injury occur : _____________________________________________________________________________________________________

l) In case of accident: i) Is it RTA : Yes No ii) Date of injury : / / (DD/MM/YYYY)

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 attach reports)

m) In case of Maternity : G P L A Date of Delivery : / / (DD/MM/YYYY)

Details of the patient admitted

a) Date of Admission : / / (DD/MM/YYYY) b) Time of Admission : : (HH:MM)

c) Is this an emergency/a planned hospitalization event?: Emergency Planned

d) Mandatory : Past History of any chronic illness If yes, since (month/year)

Diabetes (MM/YY)

Heart Disease (MM/YY)

Hypertension (MM/YY)

Hyperlipidemias (MM/YY)

Osteoarthritis (MM/YY)

Asthma/COPD/Bronchitis (MM/YY)

Cancer (MM/YY)

Alcohol or drug abuse (MM/YY)

Any HIV or STD / Related ailments (MM/YY)

Any other Ailment give details: ______________________________________________________________________________________________

e) Expected no. of days stay in hospital : days f) Days in ICU : days g) Room Type : ___________________

h) Per Day Room Rent + Nursing & Service Charges + Patient's Diet : Rs.

i) Expected cost for Investigation + Diagnostics : Rs.

j) ICU Charges : Rs.

k) OT Charges : Rs.

l) Professional Fees Surgeon + Anesthetist Fees + Consultation Charges : Rs.

m) Medicines + Consumables + Cost of Implants (if applicable please specify). : Rs.

n) Other hospital Expenses: if any : Rs.

o) All inclusive package charges if any applicable : Rs.

p) Sum Total expected cost of hospitalization : Rs.

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001 (Haryana)
Website: www.careinsurance.com E-mail: [email protected] Call us: 1800-102-4488 | 1800-102-6655 Page 2
CIN: U66000DL2007PLC161503 UIN: RHIHLIP21017V052021 IRDA Registration No. - 148
Declaration
We confirm having read understood and agreed to the Declarations on the next page of this form. (Please read very carefully)

a) Name of the treating doctor :

b) Qualification :

c) Registration No. with State Code :

Hospital Seal (Must include Hospital ID) Patient/Insured Name & Signature

Declaration by the Patient/Representative Not to be Faxed or Scanned

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 amounts over & above the limit authorized by the Insurer/TPA 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 time the facts disclosed by me are found to be false or incorrect I forfeit my claim
and agree to indemnify the Insurer/TPA.
e. I agree and understand that TPA is in no way warranting the service of the hospital & that the Insurer/TPA is in 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 indemnifo 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.
a) Patient's/Insured's Name :

b) Contact Number : - c) Email ID (optional) : ___________________________

d) Patient's/Insured's Signature : __________________________ Date : __________________ Time : _______________

Hospital Declaration
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/Insurance Company within 7 days of the
patient's discharge.
c. 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.
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 the sole responsibility 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 insured 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.

Hospital Seal Doctor's Signature

Date : __________________ Time : _______________

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001 (Haryana)
Website: www.careinsurance.com E-mail: [email protected] Call us: 1800-102-4488 | 1800-102-6655 Page 3
CIN: U66000DL2007PLC161503 UIN: RHIHLIP21017V052021 IRDA Registration No. - 148
 BREACH CANDY HOSPITAL TRUST
CONSENT FORM - CASHLESS CLAIM

List of Documents to be carry with the pre-authorization Form

1) Fully Filled pre-authorization form (provided by the hospital).
2) Pan card & Adhaar card of the Patient.
3) Relevant Investigation Reports.
4) Valid Insurance ID.
5) Cancelled Cheque of Patient Account.

Highlights:
l For all planned cases the pre-authorization form has to be processed a week prior to hospitalization. For
emergency admissions the pre-authorization form has to be submitted to the TPA desk within 24 hours of
hospitalization.
l In the absence of a valid initial authorization letter, the patient will be admitted as a Cash patient and will
be required to pay the requisite deposit on admission as per the protocol.
l At the time of submission of the pre-authorization form the patient has to pay Rs. 30,000/- as a deposit
towards admission. This deposit is adjustable/refundable depending upon the final bill and the final
approval amount of the patient.
l If a TPA inpatient undergoes an additional procedure which is not mentioned in the Preauthorisation form
then the additional documents will be processed by the TPA desk. If the approval is not received before
the surgery the patient will be treated as a Cash patient & 90% of the estimated amount needs to be paid
as a deposit.
l In case of an Emergency/Unplanned surgery the patient will be treated as a Cash patient & 90% of the
estimated amount needs to be paid as a deposit within 24 hours of the surgery.
l On the day of discharge once all required documents are sent to the Insurance Co. / TPA, it takes up to 4
hrs. for the approval to come. Patient can be physically discharged only after final approvalis received by
the hospital.
l At the time of discharge the hospital will retain 5% of the Final Approval amount as a Security deposit
which will be refunded to the patient after the final settlement from the Insurance Company, the duration
of which is variable (minimum is 45 days).

Consent:
I declare that I have been explained all the above mentioned points and I agree to the same.

Patient Name : BH No. :

Name of Person Submitting Claim Documents :

Signature of Person Submitting Claim Documents :

Date :

For Office Use Only

Received by : Date & Time :

BCHT/TPA/CON/2/03-21
 BREACH CANDY HOSPITAL TRUST
IMPORTANT INFORMATION REGARDING YOUR CASHLESS CLAIM
1. For all planned cases the pre-authorization form has to be processed a week prior to hospitalization. For
emergency admissions the pre-authorization form has to be submitted to the TPA desk within 24 hours of
hospitalization.
2. Admission will be on the basis of the authorization letter received from the TPA/Insurance Company which
is only a provisional authorization. Please show a copy of this letter on the Admission Desk at the hospital
at the time of Admission.
3. In the absence of a valid initial authorization letter, the patient will be admitted as a Cash patient and will be
required to pay the requisite deposit on admission as per the protocol.
4. If any query is raised before or during the hospitalization which requires to furnish additional information of
the Medical condition of the patient then the clarification will be provided by the Consultant/Surgeon and
may be delayed depending upon the availability of the Consultant/Surgeon.
5. If the query requires to provide any details which are non-medical in nature the TPA desk will reply to them
as soon as possible which may require help from the patient relative.
6. At the time of submission of the pre-authorization form the patient has to pay Rs. 30,000/- as a deposit
towards admission. This deposit is adjustable/refundable depending upon the final bill and the final
approval of the patient.
7. In a single hospitalization one can avail cashless only with one TPA/Insurance Company, if the patient has
more than one policy they can avail the reimbursement facility. Please contact the TPA Desk for further
details.
8. For knowing the coverage of any particular (Medical/Surgical) condition under your Policy, please read the
T & C of your policy document or speak to your agent.
9. For Room Eligibility of the patient please contact your agent for criterion of admission as per the policy of
the patient.
10. If a TPA inpatient undergoes an additional procedure which is not mentioned in the Preauthorisation form then
the additional documents will be processed by the TPA desk. If the approval is not received before the surgery
the patient will be treated as a Cash patient & 90% of the estimated amount needs to be paid as a deposit.
11. In case of an Emergency/Unplanned surgery the patient will be treated as a Cash patient & 90% of the
estimated amount needs to be paid as a deposit within 24 hours of the surgery.
12. On the day of discharge once we send all required documents to Insurance Co. / TPA, it takes up to 4 hrs.
for approval to come . The patient can be physically discharged only after approval comes as per the policy.
13. Half day charges will be levied for patients if the discharge process is initiated between 11.00 am to
1.00 pm. All discharges processed after 1.00 pm will attract full day charges.
14. The original reports and bill will be handed over to the TPA/Insurance Company for processing of the claim.
A copy of all the reports will be available at the reports counter, 7 days after the discharge.
15. A copy of the Discharge Summary will be provided to the patient at the time of discharge.
16. At the time of discharge the hospital will retain 5% of the Final Approval amount as a Security deposit which
will be refunded to the patient after the final settlement from the Insurance Company, the duration of which
is variable(minimum is 45 days).
17. Any deductions toward non-medical items, exclusions, class based billing etc. will have to be borne by the
patient (this will not be adjusted against the security deposit).
18. Please submit a cancelled cheque to get the refund into your account directly.
19. In case of denial of the cashless claim (due to withdrawal or rejection of the claim) during the
hospitalization or at the time of discharge the patient will be treated as a cash patient and will be expected
to clear the entire bill of the hospital and proceed for the reimbursement process.
20. Only approval letters received on the Email or the Portal will be considered valid.
21. There may be a delay in receiving the approval on Public Holidays or Sundays.
BCHT/TPA/INFO/2/03-21
List of Documents to be carry with the pre-authorization Form
1) Fully Filled pre-authorization form (provided by the hospital).
2) Pan card & Adhaar card of the Patient.
3) Relevant Investigation Reports.
4) Valid Insurance ID.
5) Cancelled Cheque of Patient Account.

Highlights:
l For all planned cases the pre-authorization form has to be processed a week prior to hospitalization.
For emergency admissions the pre-authorization form has to be submitted to the TPA desk within 24
hours of hospitalization.
l In the absence of a valid initial authorization letter, the patient will be admitted as a Cash patient and
will be required to pay the requisite deposit on admission as per the protocol.
l At the time of submission of the pre-authorization form the patient has to pay Rs. 30,000/- as a
deposit towards admission. This deposit is adjustable/refundable depending upon the final bill and
the final approval amount of the patient.
l If a TPA inpatient undergoes an additional procedure which is not mentioned in the Preauthorisation
form then the additional documents will be processed by the TPA desk. If the approval is not received
before the surgery the patient will be treated as a Cash patient & 90% of the estimated amount needs
to be paid as a deposit.
l In case of an Emergency/Unplanned surgery the patient will be treated as a Cash patient & 90% of
the estimated amount needs to be paid as a deposit within 24 hours of the surgery.
l On the day of discharge once all required documents are sent to the Insurance Co. / TPA, it takes up
to 4 hrs. for the approval to come. Patient can be physically discharged only after final approval is
received by the hospital.
l At the time of discharge the hospital will retain 5% of the Final Approval amount as a Security deposit
which will be refunded to the patient after the final settlement from the Insurance Company, the
duration of which is variable (minimum is 45 days).