Ghief Ministerts Gomprehensive Health lnsurance Scheme

Date Name of the patient

United lndia lnsurance Co. Ltd.

:

HospitalOP/IP no.

Sex:
Patient contact no. Diagnostic centre name
:

Age:

Name of the hospital

Doctor name

Doctors registration no.

Diagnostic procedure recommendeO

l-l

Ghief Ministerts Gomprehensive Health lnsurance Scheme

United lndia lnsurance Co. Ltd.

Referral Slip no.

1.

Name of the patient

HospitalOP/lP no.

2. Age: 3. 4. 5. 6. 7. 8. 9.
'10.
District:
Card no.

Sex:

Name of the hospital

Town:
Department:
:

Presenting complaint

Doctor's name
:

Significant past illness

Doctor's register no.

:

Positive clinicalfindings Provisional diagnosis

:

Designation

Patient contact no.

:

lnvestigations in support of diagnosis Diagnostic purpose referral

:

11.
Date

Referred to : (Name of the diagnostic centre)

Signature of the doctor

Name:
Seal

lt

Toll Free No. : 1800 425 3993

Eligibility Griteria

(a)

Any Family Whose annual income is less than Rs. 720001

Referral Slip for Diagnostic Procedures

Please

Tick ( /

the Required Procedure in the Box

1. 2. 3. 4. 5. 6. 7. 8. L

Angiogram E ECHO

tr tr
tr

Computed Tomogram (CT Scan)

Magnetic Resonance lmaging (MRl) Mammogram E

Ultra Sound Guided Biopsy

tr tr

Histopathology Examination Calposcopy

tr

Nuclear Bone Scan E

10. Tumour Markers E

11. Bone Marrow Study tr 12. Radio lsotope Scanning E 13. Diagnostic Laproscopy tr 14. Diagnostic Thoracoscopy tr 15. lmmuno Histo Chemistry tr 16. USG as an Emergency Procedure of
Facility is not Available at GH

tr

17. Metabolic Screening E 18. Fundus Fluorescence Angiography tr 19. Liver Function Test (LFT) tr

20. Renal Function Test (RFT) tr 21. Thyroid Profile, Antithyrold Antibodies tr 22. Aortogram tr 23. Karyotyping tr