You are on page 1of 3
co PAT LAM on FORTH A PUSS OIER TATRA MO FEHEONAACSDEN-ARTA | een eee eens DETARS OF PRIMARY SURED: =i Pisin OER DooooSSeooco a a gear EEE RRO TISRECC ICOCOeOo0o3 vows (Ore IBC AL ED De aS aieleiaiaiatar a SEE AECL TI 0008 cms RIEU) no TOTO AU AMC adayseny 9 44 Symaits Aim oMyaywikiiinhn eT Waiommeiokemavcetes(ss) AE) WOME ni ots rere IO OOOOOOO000000 nam DOOOOOSOSOCNOOR EAA j sonra) CCCI Later toentaptatad set yrs atb centr? CIyee C0 3 apes palanla nent, ce Drm teres COOOUOOOO000000 eT 0F Nae PERSO SLE ees vm, COPE BEMEECOOE 5 eB Sree BI] ‘ome [BI] oo ean a som] oH) ree C] tne [] ote [ssc eee! __— examin Sonia" sattnaoes [] a aoae rset] one C)remesessy [ one 9 Ades ten toms anc Cie es WIOOOOOOoOoOoOooeo00oo Soocogeer Cece ou! OOOOSOoOoooOoooonoonono = ACCOUOUOSOS00000000 CO0IODRCORORSHO0000 ee AOOOOD «OOO00000000el— OO 7050 ei omrerareCIOOOCAoooIcO000 of eon] ovcgtscatin dete oy CD a4 ay] eecmchcenesnnameans ne Ba eeze secon (IE) IS) EE) HIE IB) secon] TE} v rm» tities [Route C] Stateline Common] guteseo gd] YE Ho i i nremetiorace CC] AMcReecaReriomdes ves] = | i 8 3 : Hl IRAE eARAEEOO (S181) ‘bealbetemetoe - 1 Pte pee 20 A Hopttonepate Be mmo 3 cam loma ates Postpones re veamomcupeot —® CICICICICALIL] Ol covetiecamitatn any poten Cae = Oooocoo eto = Qo0Oo00oo ees YD rrpotsnston sa = OOo0o0o000 ve retetaatamet —— on IO ra epiatopese om — COC] h-rareninanene chingrDoseuytisi: ——] Ys] tyne etn amenre) AEF theme 8t tt tan Ch comer agen OOOO0O0 twee » OOOOOOO os ca ee sOOO0005 some: © DOOSO00 Sessa nasegst craretetioumemedes OOIOOOO vo OOO « BOOSbo0 ister « Ooooooo ‘ao erase aus nes: ‘Sal Be Troan RL lellelee eles =[=l=l=lele[=|2|=[9|-| IBA ES@eOIII00 ORDA SSOGOUBR SKOOOANOEE Oe! ceo 00 Pye oncom ESE BOMOSIAEEO0 O01 {PORTANT PLEASE TUR OVER) DECLARATION BY THE WsuRED: a de et ra re vn pe nn nna en repens ecsntesmtmy aa mite a ote Sone oceiayea es eran tea ana met ante ore on es [ereby deca th have cis athe is! ece fore purpose of Pec & fat | wl tbe rakeg ny supplementary ca exept Oe x ow BB) 81) EAS) {THANE Sona often ‘Ga FOR FILLING GLA FOR - PART Ao ben th are DARLENE T DEsenrTON T BEETONA-DETAES OF PRIARY RSURED [2 Bater no. [2S OO 734722 foes] O0000GHT ene poy mortar ‘aloe bye ewrnicn Company Ee Ae scalar bar ara co aE | 4g atc the organiza FoR mm 1 NotL535 8) S.No! Conese, Seaniewenay sce anc i oT Wy ROR Grd nd ©) _GonpanyTPA ONO MOTS-003034 414 | Erertie TAINS Wawerca None AORN SONY STKANOAQ| Ste ha tnane ita piohae Sue, Fst nae se na ais Erbe Alps less Teh Set iy aed code [RLAlao& ViMMDL DAIRY Une By OR Te na SERIE ORR UNG Nan Taran 1) _ ne of conmenconete a nakence ica ea | ner of csonencane tr ran Testa armel Conary Name — Eire woe irre Comer Nan he eieston Pato ree paleyrber dy res Corn) Samar rors er et a alo rest Five ya bea PSRORTR ATOR Lacan aiaik balatiar nes oe Ineapln ftw conrec? oe ho fcr = ats Eire do eaabon aay oa Deg Erie dope dots Open Tot a Pi A a MOST a fmt Mon ares 7 Gampeny Nae Ent ns i ean oT Rael oon >] ‘SECTION ¢ DETAILS OF NSURED PERSON HOSPTTALIZED D_NameYROAN SONG _STRANOAE| crane tatname tne pasar, ‘Suman Fat nme, ene Tek or Foal een f CMIBLE a 29 Ens ge be at af nd me 0 osnaom — fey = OF 18S rat ear Ue sama oma a) Rete ona re re ine rr of pte pa i hota, an 7 ines ong pate Tk igh cpton Wath, ae pec 9) Address ame Bic abo ie he fal postal address ‘ncude Stree, City and Pin code no Pwete gags LONG rr hve mb tao Inde STO cde wh phone Tabor Eat v © Grr ocr eal astra Cpls al are zs cron -DeTALS OF HoSPTALEATON 3) Nana oan we sid MALL LAT NURSTR tsk nabs shoal 3) Room etigy ed 9 TAGLC OCESL pancy_| nsec eto SE Tih i pon [Ter Mospiatation ave to GOO [re cate ronson of hospllalzaton | Tick the right option [a Bacotnno gs fees Oe | Fer relvon te se dey oma J bateatooamson 9 JO [ 2033. nr a dion es ayaa 2 2+0D ini ete ora ar beams 9. | OS[ DORA | eure were es dey orm 3 Te 1a 6D Eres aaa Test ot 1) iy See Ta ene oy Tk i op iteoles Tae wari nee Tavern Repent Pee Tia whi ple rept as ed TaYesartie NEG Rape Pen FR med Tae wer MC pe na Pee aia Teese eae ine eae ede wen Veaig te pe | pene 3) Details of Treatment Exences C1 Q(B Ol — | Enter tne amount dimes as veaiment expences ‘nrupess (Oo not enter paise velies) [1 Ge oon Penta ine eter da se dil tsps Tek Yer ro 2) ett a xc bl cine he cn dined pe eth beat Thngect Bo oan les whee) 3} hi vorrei Cesk Lt ina i apt Snare ig Tee ston ‘SECTION F-DETAUS OF BILLS ENELOSED ‘rai ih nun wh atm apes ie ‘SECTION G DETAILS OF PRIMARY NUREDs BANKABCOUNT aoa oF ar poner es RT 3) Acomattunte {OQ 4022 PH 2 _| Sere taser easy Bare RG oo Taran «)__ Cheque! DO payee diate Trae elton oaneany Be Segue TOD SCS | Wome fe inadue rgenzaton tl 3a Cae ee FSC aah Ba FC ae cea war ‘Ran acon cary and ron a (BH omaT Rae open waa CLAIM FORM - PART B ‘TO BE FILLED IN BY THE HOSPITAL The ferue of hie Fo is notte than a= an admission fi (Tobe ried boc ters) ETAILS OF HOsPrrAL Please Include the orginal preauthorizaton request form In leu cf PART A seme ttt iabadisaoRre@sasaercCaNsloCLoCcoCSoccooal eee Ooo0000000 petit Mee: [Nana sonnet cn) Nertinimce: CRE ED BE OOOOUSIEI AaCCENooocracn | samieacs — OGD FPS trum encore (BIE 4 orm BIDBEIABAIEIBISIS) * DETAILS OF THE PATIENT ADMITTED JOOOUOEBAy CORSE OOSEeAeeeeaeso ede: Mit] Feri dono IES] Home) omen OG) BH , novectrensien TE) (61S) YS) atm IE) IE] — noone: (ST CSB) orm: COG) elf Diipectamesin: gency] Parnes FA“ boy cow) watenty C] gute naesoeiy: [OTS] H)] 19 Grae Stat oon Site tte duce: Octane heme TA Osage towbars [] Deas C] smdindnent § COOO0000 DETAILS OF ALENT oANOSED PRIA ° rowers sn » veowns besos temgoeres § OOO0000 ns wean © — OOOOO0O srscordoere: QOOOO00 (| | tenes = QOO0000 homie § OOO0000 amas OOOOO00 nome QOOOOOO (=== J wort Freshen sad Oe Om oreeteaome OOOOOOND000000 Natron dyrawat bres, greemen, © [OO Apatite, COW Cte itepecnse sted] dttetetet [] Sina etlonametn iy oases tse eh mean Teen ethic CJC] Ne Wea) Kunst] Yer C] Ho ieRapnaierain Cle No eee OOO OCOCOOD remnant <> Dl comremsm aes YET mnt D1 oteatrnntretenenes LEE cans ment 1 ottePeateen oar {ET beset Bexar aces tht O « VET wot my 1 Pama Oni Batis Memes Everson Ct mot ep Geren Pept ss {ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILLINGASE OF NON-NETWORK HOSPITAL) waver TEI DISMOREADOIEIOCETOSCESECOOUUERROBEOOO TRG ESHEaABRoOBeOoOoooooooooooo0oo0ooOo0oo00000 » MORBESODOOOOODCOO™ MABRRRSIMRAQOOOOOOO , roc AOSAITIEE rove SAAS AALICIEIES oraysnans wnt Fee Toooeys arooatpme — PHPRTICONIE TEI IPIES civmersteonentes (SJE YD) srediesoaiteinrensyis cor Efe Che vic ese) Ronen C DECLARATION BY THE HOSETTAL (PLEASE READ VERY CAREFULLY) ‘eh cn tale tem thom es eb aa yt ep Ciigatdon rr become oe Bl] BIB) BIB) we [ MomeAt ) Seated eter Athoty LS A C02 TE 2 N00

You might also like