STAR HEALTH AND ALLIED INSURANCE CO LTD.

,
NO.15, SRI BALAJI COMPLEX, 1 ST FLOOR, WHITES LANE, ROYAPETTAH, CHENNAI-
600014

QUERY ON PRE AUTHORIZATION

DATE : 25-SEP-2017

TO,
HOSPITAL : PRANAV S ORTHO CARE

ADDRESS : POLLACHI ROAD,

Dear Sirs,

We are in receipt of Pre-authorization request from your hospital for treatment of the insured-patient as per details
given below:-
NAME OF INSURED-PATIENT : P.KATHIRVEL AGE : 35years

DATE OF ADMISSION : 24-SEP-2017 SEX : Male

NAME OF POLICY : FHO Revised 2017 ROOM CATEGORY : General Ward

POLICY NUMBER : P/121311/01/2018/001753 DIAGNOSIS :INJURY

CLAIM INTIMATION NO. : CLI/2018/121311/0328075 TREATING DOCTOR :

Our Medical panel has processed the authorization request and other documents. The panel requires the following documents / details also
:-

KINDLY REVERT WITH

1.EXACT CIRCUMSTANCE OF INJURY(TIME,DATE AND PLACE).
2,SELF DECLARATION LETTER.
3.MLC/AR/FIR COPY.
4.DETAILED LINE OF MANAGEMENT AND CASE SHEET ON ADMISSION.
4,FIRST AID TREATMENT RECORDS.
Please therefore send us the above documents / details for our further action.

sh42515
Authorised Signatory

25-SEP-2017 02:48 PM

Note: Please hand-over the copy of the letter to the Insured Patient.

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in