APPLICATION FOR INDOOR CASE PAPER

Date: _____________________ Receipt No: _____________________________

Set of Copies Required: ____________________
Courier Required: Yes / No

To, Address if documents to be couriered

The Medical Director __________________________________________
Breach Candy Hospital Trust, __________________________________________
60-A, Bhulabhai Desai Road, __________________________________________
Mumbai – 400 026. __________________________________________
Pin Code:
Respected Madam / Sir,
I request you to kindly issue me a photocopy of INDOOR CASE PAPERS of this admission for the
Purpose of_________________________________________________________________________________
Following are the patient details
Name of Patient
Admission No.
Date of Admission
BH No.

(Please fill: In case of the person collecting documents is not an applicant)

I hereby authorize Mr. /Mrs. /Ms. ____________________________________________to collect a copy of

Indoor Case papers on my behalf.
Thank you,
Signature: ___________________________________________
Name: ____________________________________________ Mobile No. : _________________________
Relation with Patient: Self/Husband/Wife/Son/Daughter/Father/Mother/Other_________________________
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Please retain this counterfoil for your information
a) Please collect Indoor Case Papers form following address after 5 Working days from application.
*Medical Record Department
Mahalaxmi Chambers, 5th floor,
Near Swami Narayan Temple, Opp. Tirupati Apts., Above Union Bank,
Mahalaxmi, Mumbai- 400026.
Please show Original Payment receipt at the time of collection of Documents.
b) The charges are as follows:
 1 set of Indoor case papers - Rs. 150
 Courier for 1 set of Indoor Case papers - Rs. 200 (150+50)
c) Photo ID is mandatory for the person collecting the documents
d) You can also pay online through NEFT/RTGS to Breach Candy Hospital Trust
Bank: Kotak Mahindra Bank, Acc: 3011206652, IFSC: KKBK0000637
(Please Share Transfer details along with patient details to below mentioned email ID)
Phone: 022-23557322(8:30 am to 5 pm Monday to Friday, 8:30 am to 12 pm Saturday)
Email ID: mrd@breachcandyhospital.org