STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED copes nto an Cr Rn ‘unr 40004, con-uonancn Eatennareogaanann wna AIR 2 REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART -c (Revised) DETAILS OF THE THIRD PARTY ADMINISTRATORINSURERIHOSPITA (70 BE FILLED IN BLOCK LETTERS) 4. Name of TPAesurance company ‘STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED Tle phone nner «Tete fax Name et Hosp: Less Rohini Remalia ‘TOE FILLED BY INSUREDPATIENT A. Name of te Paint pee oy Fomaie Third Gondor Cas (Yeas) (Men) . Date of Bi (oonmevvryy EContactrunber: Contact numberof sending Reatve: 6 swe Crd 0 numba: H._ Paley nunberNane of Corporat: 1 Empoyee 0: 4 Curent do you hae ary ther mei heath insurance: ww] »[_] \Conpany Name: liGve Deas: KDoyouhve afi Physic: Yes No L._ Nama ofthe famiy Physica: Mi. Contac umber, any N. Curent sees of Insured Pain: (© .Cccupaton of Insured Patent (PLEASE CONPLETE DECLARATION OF THIS FORM)M. ‘TO BE FILLED BY TREATING DOCTORIHOSPITAL Name ofthe treating Doctor: Contact number: Nature of ilnessDisease with presenting complaint RelavantCatcal Findings: Duration ofthe present alment —______ bays |v, Date of First consultation emmy ¥Pasthistory of present ailment, fan Provisional diagnosis: oD Wo code Proposed line of treatment: L Medical Management ‘Surgical Management IL Intensive care I. Investigation v. Non-allopahic treatment Ifinvestigation andlor Mecical Management, provide detals: Route of Drug Administration Ir surgical, name of surgery |. 10D10 PCS code other treatment, provide deta How did injury occur In case of accident: i. IsitRTA |, Date of injury li, Report to Police Iv. FIRNO \. InuryDisease caused due to substance i. abuse/ateohol consumption Vi. Test conducted to establish this (ifyes, attach report) Incase of Maternity | expoctod date of Delivery oo (oominrrvy)DETAILS OF PATIENT ADMITTED ‘A. Date of admission (oommuvyyy) 5. Time of admission: (Hein Is this emergencyiplanned hospitalization event Emergency D. Mandatory Past History of any chronic ines ‘tyes (Since month'yest) 1. Diabetes| |i, Heart disease Osteoarthritis Asthma/COPD/Bronchitis Cancer Aleohol/Drug abuse ‘Any HIV or STD Related ailment Rheumatoid Arthritis Cerebrovascular Accident Stroke) Liver disease Kidney disease xi, Any other ailment.give details Expected numberof Daysi/Stay in hospital Level / Grade of Surgery: Days in ICU: Room Type: Per day room rent + nursing and service charges ‘patents diet: Expected cost of investigation + diagnostic: ICU Charges: (OT Charges Professional fees Surgeon + Anesthetist fees + consukation Charges: Mecicines + Consumable + Cost of Implants (if applicable please speciy) ‘Other hospital expenses if any ‘Altinelusive package charges i any applicadl ‘Sum Total expected cost of hospitalization:DECLARATION (Please read very crf A. Name of the treating doctor B. Qualification CC. Registration number witn state code Hospital Seal Patontinsured Name and Sign (Must include Hospital Id)DECLARATION BY THE PATIENT / REPRESENTATIVE | agree to allow the hospital to submit all orginal documents pertaining to hospitalization tothe Insurer.PA afte the discharge. ‘9gre¢to sign onthe Final Bil & the Discharge Summary, before my discharge, Payment to hospitals governed bythe terms and conditions of the policy. In case the Insurer TPAis nolliable to sete the hospital bil, undertake to settle thebillas per the terms and conditions ofthe policy. Allnon-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized bythe Insurer/T.P Anot governed by the terms and conditions ofthe policy willbe paldby me. I hereby declare to abide by the tems and conditions ofthe policy and fat any time te facts disclosed me ae found tobe false or Incorrect foreitmy claim and agree to indemnify the Insurer/PA | agree and understand that TPA is in no way warranting the service of the hospital & thatthe Insurer / TPA is in no way ‘guaranteeing thatthe services provided by the hospital willbe ofa particular quality or standard. 'nereby warrantthe truth ofthe forgoing paticularsin every respect and agree thatif have made or shall ake any false oruntrue statement, suppression or concealment with respect tothe claim, my right to claim reimbursement ofthe said expenses shall be absolutely forfeited agree toindemnty the hospital againstallexpenses incuredion my behalf, which arenot reimbursed by the Insurer/TPA “Wie authorize Insurance Company/TPA\ocontactmalus through mobilelemallfor any update on this claim” Authorization to Star health and allied Insurance Co, Ltd am admitted in your Hospital from hereby authorize Star health and allied Insurance Co, Lid. and its representatives, who is my Health Insurer to seek any ‘medical information / records from you or from the Medical Practitioners who have attended on me in connection with the above ailment and the treatment given. In ease they seek any such information / records indoor ease papers, kindly oblige 2) Patients /Insured's Name ') Contact number 9) email id 4). Patient's /Insured's Signature DateHOSPITAL DECLARATION ‘We have no objection to any authorized TPA, Insurance Company offical verifying documents pertaining to hosptalization, ‘Allvald original documents duly countersigned by the insured | patent as per the checklist below willbe sent to TPA/ Insurance Company within 7 days of the pationts discharge. we agree that TPA I Insurance Company will not be Liable to make the payment in the event of any discrepancy between the fact in this form and discharge summary or other documents ‘The patient declaration has been signed by the patient or by his representative in our presence We agree to provide clarifications forthe queries raised regercing tis hospitalization and we take the sole responsibility for any delay in offering carfiations. ‘We wil abide by the terms and conditions agreed in the MOU \We confiem that no aditional amount would be collected fromthe insured in excess of Agreed Package Rates except costs towards non-admissible amounts (including addtional charges due to opting higher room rent than eligibilty choosing separate line of treatment which isnot envisagediconsidered in package). We confiem that no recoveries would be made from the deposit amount collected from the insured except for costs towards ‘nor-admissible amounts (including additional charges due to opting higher room rent than eligi! choosing separate ine of treatment whichis not envisagediconsidered in package). In the event of unauthorized recovery of any addtional 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 fr take: necessary action, as provided under the MOU or applicable laws. Hospital Seal Doctor's Signature ee roe