smearterosns DOT OOOOOOOOG OOOO OOOO ehalerat QOOOCOOCOOONG REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY Z PART C (Revised) ‘Names Tconomy, Med Assist surance TPA PU Fits GBD 206866 soranestse rene weeds pte he tos IF] soe fz] oe cor [TTI act OOO [teceeser aco CoCo ose ULsD IBLOCK LETTERS DNC 0000000000000 COOCC 00 = COOO TT Tal nwa eA 559 LI] DO OAOCC OCC OOOC OCC Oc OOOO feZCOOCU0O LIT OOOO Peaiyeyenecsvonemccrcinsmianess [fu fe Warr REC CE UL OLEESEECOLo lave ‘yboyau hea onan =o veers COOOL COCO OOO0OC000000000 === 000000000 ec sientemieees SECOSDLEDIEDELE 00) Ye" OOo fish Guide ememmntn J] oJ) «oo weet Dee ‘Sletandaett eno siya [fos [po taped ine other: PTI weeee 000000 Wesdiome ETE] 6 ener [poms a a ae oa ean OEDAnt REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY Q PART C (Revised) TORE FLED N BLOCK LETTERS — 3 Sincren ed reorient tgnsenecope shan ie) i amps ag cent pmrrnh Inowetecen erasnton sot s UOSIGOZIEE] oo * DEEL fe “DOOOOnoo Tagega Use ~(golebIAEIOA [Lj soxeontots : “ ® CII) C)smmeororaerents eat *QU000. 00) 0) Sum ota expected con afhoupitalization «Fla, “we . AS EPO a ryateratentone ces: DECLARATION LEA NAD VERY AEF) odd geet ecedaston stom snemtmnatacs: TR TOIEMPATE qo oooooooonOoonoooo ee ET TT EEE eseeemenones CE CCEOCLE ager ron oee ety een sehaneechgs agei aonb r BLA ReDePwne a e enécoaon ote nce ier TPA ain he een ha em part ems ascend re eros or ots usin uPA goede tm cen cio sence as hx te ser Phi ow seater srs owed Pe xp Weta rexeaooge lf nae al aie my ert Sora, sua cresinen Wh egne De POCCCOLCCECooCooLoocnoeeocc )) eee OOOO OOOO 000000 ome PUT we IEE] PERE = Seer Fae To aa TESTSGIPSA_NE} -DECLARATION FORM by ghe Hospi) {oi} So _bate of Admission LS 26120 Name of the Hospital: address: PATIENT NAME/INSURED NAME (BLOCK LETTERS): Nana Sle Lleeramma {Tobe filled by the insured/poicy holder/Attendant) 1. Do you have an Insurance policy? yes/no If yes, then please select: New India/ United india/ National Insurance/ Oriental Insurance/others Policy No. TPA Name. Wie dk as — TPA cord No. tO 2¥ OUOGO 2. Have you contacted TPA or Insurance Company for cashless facility? “YES/NO 43) Whether patient opted for Elgble Room Category under Policy: YES/NO If No, then kindly mention the opted room category: (On my own option, | wish to avail above facility and | hereby agree to pay on my free will, after being explained in detail by the Hospital authority in my own and understandable language about the above mentioned Facility/Procedure/Treatment and associated cost of it, which is over and above the agreed tariff for the treatment. Further, if | opt to go for final bill reimbursement with insurance company, respective insurance company will reimburse only as per agreed tariff for the treatment and balance amount will be borne by me / patient only. | have also been explained that when roam service ofa category other than eligible room rent is availed by the patient, not only the difference in room rent but also an-equal proportion of all other charges associated with the treatment shall be borne by me/ patient fly a C Signature Signatures 5mm Name of the Patient/Patient's attendant: Name of the Hospital’Representative &Hospital Seal: Mobile Now SOS SS. E-Mall PAN / Form 60: ‘Aadhar Card Number.: athe Heeramma Member Id 4028040601 Date of Birth 02-Dec-1968 Relation Mother Effective From 14-Feb-2020 Policy Holder Intel Technology India Pvt Ltd Insurer Member MEMBER33097 Id‘sazcs oxy / Enrollment No, : 2017160364/00028 2areb eng, RAS ‘asrgeitesnes ome seu Sie eg oossri2ser ‘Sb eser5 Hoa / Your Aadhaar No. : 3037 9925 4923 aonb — PaPAAD PLY, teats, ‘ARDHAAR 3 | % word ragesnen apbuce, drsaergne mes. 5 Ageot aeen v8 BS wats yr ey. INFORMATION ® Aadhaaris proof of identity, not of citizenship ' To establish identity, authenticate online. |r ers enccer erences = word SDQygos" gedes stats gadis dew woddaivced" ava Scav0d. ‘= Asdhars valid throughout the county. I ‘= Aadhaar will be helpful in availing Government | | ‘and Non-Government services in future, | 2938 bea, Depevath Heras cage ncn 08 Sensis 3037 9925 4923 rb — PAPAAD TS, caver wo ase exe Adee: WO: Depth vans sagan Na =n limit See Bo = | eee 3037 9925 4923 = ia ol. =._ tSlo6G rer? a jgeknor Reddy POC, on a Dobotoogist . “Ke K 1 M Ss mePnpi fen HOSPITALS” Vitals: “ baad Temp MLS Lajeshme YH eaiamne prio & ug Y¥ FE Bp:[21 /@OmmHg Sp02:4S % RA fou dy wd pogo dsl Sp Get pyeo 7 & | yw? Puyeat~ : t oat Mp IF i ny veal the Pe” ; dt ae ; oe B iz eu t Ca \ s-uzyue Survey a SE7EE Rondon Vig Serttbompalf Cote oreoad er pyriL), Gee wot Je is bovat Be Reet — Bas tote Mv, 7 — Pu cm yo ~ (es a nt 6