In Patient Estimation

Admitting Location : Patparganj

Expected Date of Admission : 14-September-2017

Expected Length of Stay : 1 Day(s)

Estimation No. : EHPG/ET/66797 Ver. 0.2 MaxID : EHPG.685968
Estimation Date : 14-September-2017
Patient Name : MRS KAMLESH . Admitting Physician : L Tomar

Company Name : ICICI Lombard General Insurance Co

Ltd (2016)-PPG
Sl.No. Service Name Day Care

1 The Castestimate
cost AE/AK (Without
is basedReduction)(Surgery)(*)
upon the proposed treatment plan 13,680
and the requested bed category. The actual billing may vary depending upon patient's medical condition, treatment
2 ordered byBK/BE
Cast the attending
(without physician
reduction) & services availed during 6,143
Ortho(Surgery) the patients stay at the hospital.
(*)
The above cost estimate is prepared for a regular patient and indicates the likely average of the range of costs observed in the episodes of such treatments undertaken at the
3 Room Rent 2,200
hospital.
4 Consultation 2,000
The underlying information used to determine the length of treatment; services that are commonly provided as part of the treatment; and the frequency of the provision of
5 Others () 2,000
these services are derived from the recent six months of episode data. This assessment is evolving continuously based on actual patient engagements and therefore should be
6 Pharmacy 7,000
considered as indicative only.
7 The estimated
Consumables 2,000 prior to the commencement of the procedure.
cost for the treatment is required to be deposited
8 A change in treatment
Laboratory Servicesplan may lead to a revised cost estimate
1,500for the patient. You are requested to contact the Front Office in such an eventuality.

9 The Other charges

Radiology mentioned in estimate includes Physiotherapy,
Services 2,000 Blood Bank, Consultations, Medical Equipment and other similar services.
10PleaseMedical
contact Front Office
Supervision team for any additional information/
Charges 2,000 clarifications related to the estimate.
DECLARATION
Bed wise Estimated Total : 42,523
I / we undertake that :
I/We have understood the details of estimation as well as the indicative nature of the estimate and shall coordinate and cooperate with Front Office team and adhere to
proposed payment / deposit schedule as explained to me/us.

I/We will clear all payments/dues not covered as per the insurance provided by my/our employer or any other third party.

Further, I/We shall abide by any revisions made by hospital based upon any change in treatment plan and also abide by the hospital regulations during my/our visits and/or
stay in the hospital.

Print Date : 14/9/2017 3:09:56PM Note: This is an approximate estimate based on historical data. It will vary on a case to case basis. Page 2
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 In Patient Estimation
Admitting Location : Patparganj

Expected Date of Admission : 14-September-2017

Expected Length of Stay : 1 Day(s)

Estimation No. : EHPG/ET/66797 Ver. 0.2 MaxID : EHPG.685968
Estimation Date : 14-September-2017
Patient Name : MRS KAMLESH . Admitting Physician : L Tomar

Company Name : ICICI Lombard General Insurance Co

Ltd (2016)-PPG
Sl.No. Service Name Day Care

This estimation is only valid for next 10 days.

* As per bed category

Sonam Singh

Patient Care Coordinator Patient Attendant Consultant

Print Date : 14/9/2017 3:09:56PM Note: This is an approximate estimate based on historical data. It will vary on a case to case basis. Page 3 of 3