CLAIM FORM FOR HEALTH INsURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PARTA

TO BE FILLED IN BY THE INSURED

The issue of this Form is not to be taken as an admission of liability

HERITAGEHEALTH
IRDAI License No. 008
DETAILS OF PRIMARY INSURED: (To be filled in block letters)

a) Policy No
2sIios2iolo
c) Company/TPA ID No:
3 b) s1 No/Cntlficato No
HS-o7o o6 7lo32L
d)Name la los KUlm ARLLLLLL
e) Address
HARNA GnlR
City ADODARA
I 1 State:
|JA R A|1|
Pin Code:9 2 Phone No 4 s 8 2 4 7 6 | 3 Emal 1 p r u b o n b o l r e m a :C
DETAILS OF INSURANCE HISTORY:
a) Curently covered by any other Mediclaim/Health insurance: YesNo b) Date of commencement of first insurance without break

c)If yes, company name:

Sum Insured (Rs.) d) Have you been hospitalized in thelastfour years since inception ofthe contract 7 Y e s
e) Previously covered by any other Mediclaim/Health Insurance: Yes No ~
Diagnosis
fIfyes, Company Name
DETAILS OF INSURED PERSON HOSPITALIZED:

a. Name A laululs RDMaRLEDEETLM E TIMDLELAMT

b) Gender Male Female c)Age: Years 3 A Months i | d) Date of Bith: o 2 3 1 2
e) Relationship toPrimaryInsured: SelSpouseChildFather MotherOher(PleaseSpecity
nOccupation. ServioeSelfEmployedHomemaker Student Retired otherPlease Specify).
g) Address (if diferent rom above): SAMEHLL

City: State

Pin Code Phone No Email10L

DETAILS OF HOSPITALIZATION:
a) Name df Hopis vhere Atmits DLITISFECUALIIY HCS|PTTALI
Single occupanc Twin sharing 3 or more beds per room
b) Room Calegory occupied DaycareJ. d) Date of injury/Date Disease first detected/Date of Delivery L
c) Hospitatization due to
Injury lness Maternity
e) Date of Addmission: a 2 Time: OEala]Pm 9) Date of Discharge : A 2 ) Time20c
) If injury give cause: Selfinflicted Road Trafic Accident Substance Abude /Alcohol Consumption i) f Medicolegat:YesNo
m) MLC Report&Police FIRattached YesNo ) System of Medicine.
i) Reported to police :

DETAILS OF CLAIM
e N
Claim Documents Submitted Check List:
a) Details of the treatment expenses claimed

i. Pre-Hospitalization Expenses: Rs. i. Hospitalization Expenses Rs. Claim Form Duly signed
Rs. Copy of the claim intimation, if any
Rs. iv. Health-Check up Cosf
ii.Post-Hiospitalizalion Expenses Hospital Main Bill
. Ambulance Charges : Rs. vi. Others (code): Rs
Total
Hospital Break-up Bill

vii. Post-Hospitalization period: Days Hospital Bill Payment Receipt

vii. Pre-Hospitalization period Days
Hospital Discharge Summary

b) Claim for Domiciliary Hospitalization

(if yes, provide details In annexure) Pharmacy Bll
Operalion Theatre Noles
ECG
c) Details of Lump sum / cash benefit claimed:
Rs. Doctor's request for invesligation
Hospital Daily Cash Rs. ii. Surgical Cash:
iv. Convalescence Rs. hvostigation Reports (includ ng CT/MRIUSG/HPE)
il. Critical illness Benefit Rs Doctor's Prescriptions
v. Pre/Post Hospitlaization vi. Others Rs.

Lump sum benefit R II Total

Rs. Others

DETAILS OF BILLS ENCLOSED

SL.No. BillNo. Dale Issued by LTowards LAnount (Rs)

Hospital Main Bill
Pre-hospitalization Bll Nos.
Posl-hospitalizalion Bl: No0s.
Pharmacy Bills
DECLARATION BY THE INSURED:
Iherebydeclare that the Information fumished in this claim form is true &correct to the best of my knowledge and belief IfI have made any false or untruestaternent.suporesson
conceaiment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shallbe forfeited I aso conseni a o e
TPAInsurance company. to seek necessary medical infomation/ docunients from any hospital/ Medical Practitloner who has attonded onthe person agansthomnisi
made. I hereby declare that i have included al the bills receipts for the purpose of this claim & that I will not be making any Supplementary claim oxcopt the prelgost-nosp1a1230
claim, if any

Date Place Baroda Slgnature of Ihe Insured

GUIDANCE FOR FILLING CLAIM FORM -PART A (Tobefilled inby theinsured

FORMAT
DATA ELEMENT DESCRIPTION
OF PRIMARY INSURED
SECTION A DETAILs
Enter the policy number As allotted by the insurance company
a) Policy No. As allotted by the organization
Enter the social insurance number of the certificatee
|b) SI. No.JCertificate No.
number of social healthinsurance scheme
License number as allotted by IRDA and
c) Compary TPA ID No. Enter the TPA ID No.
printed in TPA documents
Enter the full name of the policyholder Surname, First name, Middle name
d) Namee
e) Address Enter thefull postaladdress Include street, City and Pin Code
SECTIONB- DETAILS OF INSURANCE HISTORY
Indicate whether currently covered by another TICk Yes or No
a) Cumentiy covered by any other
Mediclaim/ Health Insurance? Medicliam/ Health Insurance
b)Date of Commencement of first insurance without break Enter the dale of commencement of irst insurance Use dd-mm-yy format
c) Company Name Enter the full name oftheinsurancecompany Name of the organization in full
As allotted by the insurance company
Policy No Enter the policy number
Enter the total suminsured as per the policy In rupetES
Sum Insured Tick Yes or No
d) Have you been Hospitalized in the last four years since Indicate whether hospitalized in the last four years
inception of the contract?
Date Enter the date of hospitalization User mm-yy format
Open Text
Diagnesis Enter the diagnosis detalis
Indicate whether previously covered by another Tick Yes or No
e) Previously Covered by any other
Mediclaim / Health Insurance? mediclaim/Health Insurance
Name of the organization in full
Company Name |Enterthe full name ofthe insurance company
SECTIONC - DETAILS OF INSURED PERSON HOSPITALIZED
Surname, First name, Middle namne
Enter the full name of the patient
a) Name
b) Gender Indicate Gender of the patieent TickMale or Female
C) Age LEnter age of the patient Number ofyears and months
d) Date of Birth LEnter Date of Birth of patient_ Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick theright option,if others, please specify
) Occupation Indicate ocCupation of pationt Tick therighloption,ifothers, please speciy
g) AddreSS Enter the full postal address Indlude street, City and Pin Code
h) Phone No_ Enter the phone number of patient Include STOcOde with telephone number
)E-mall | Enter e-mail address of patient Complete a-mail address
SECTIOND - DETAILS OF HOSPITALIZATION

Name of hospital in full

a) Name of Hospital where admitted Enter the name of hospital
b)Room category ocCupied Indicate theroom category occupled Tick the right optlon
C) Hospilalizalion due to Indicate reason of hospitalizatiorn_ Tick the righl option
d) Date of Injury / Date Disease first detected Enter the relevant date Use dd-mm-yy format
Date of Delivery
e)Date of admission
Enter date of admission Use dd-mm-yy format
Time Enter time of admission Use hh:nmm format
9) Date of discharge Enter date of discharge_ Use dd-mm-yyforimat
h)Time Enter time of discharge Use hh:mm format
) It injury give cause Indicale cause of injury
Tick the right option
If Medico legal Indicate whether injury in medico legal Tick Yes or No

Reported to Police Indicate whether police reportwas (lled Tick Yes or No

MLCReport &Pollce FIR attached
) System of Medicine
a) Details of Treatment Expenses
b) Claim for DomiciliaryHospitalization
C) Details of Lump sum/cash benefit claimed
d Claim DocumentsSubmitled-Check List
Indicate which bills are enclosed with the amounts in rupees
Indicate whether MLCreport and Police FIR attached Tick Yes or No
Enter the system of medicine followed inIrealing the palient Open Text
SECTION E-DETAILSOF CLAIM
Enterthe amount claimed as treatmentexpenses Inrupees (Do not enter paise values)
Indicate whether clainm is for domiciliaryhospitalizalion Tick Yes or No
Enter the amountclaimed aslump sum /cash benefit Inrupees (Do not enter paise values)
Indicate which supporling docunmentsare submitted_ Tick the right oplon
SECTIONF - DETAILS OF BILLS ENCLOSED
 CLAIM FORM -PART B
HH
HERITAGEHEALTH
TO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liablity
Please include the original preauthorization request Form in lieu of PART A
(To be filled in block letters)
IRDAI License No. 008
DETAILS OF HOSPITAL

a) Name ofthe Hospital

b)Hospital 1D c) Type of Hospilal Network Non Network (if non network fil section E)

d) Name of the treating doctor

e)Quallfication M 9Registrallon No. with StateCode L 9) Phone

No
DETAILS OF THE PATIENT ADMITTED

a) Name of the patient

b) IP Registration Number L L L I L c ) Gender: MalelFemale Years3 d)Age: Months e) Date

ofBirth:|o27
1) Date of Admission
h) Date of Discharge: P 2h 9Time 20 e
)fMatemity i) Date of Delivery:D| ) Gravnda
Status
) Type of Admission EmergencyPlanned Day Care Maternity
m) lotal claimed amount 9 Jo|i9
1) Status at time of discharge Discharge to home Discharge to another hospital Deceased

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

ICD 10 PCcs Description

ICD 10 Codes Description )
2)
i.Procedure 1
i. Primary Diagnosis

ii. Procedure 2:
ii. Additional DiagnoSis

ii. Procedure 3
1. Co-morbidities

iv. Details of Procedure

iv Co-morbidities

c) Pre-authorization obtained : YesNo d) Pre-authorization Number O

reason:
e) If authorization by network hospital not obtained. give
Substance abuse /l alcohol consurmption
) Hospitalization due to injury i. if Yes, give cause Self-infiicted Road Traffic Accident
Substance abuse/alocohol consumplion, Test Conducted to establish
this:
Yes No (f Yes, attach reports) ii. f Medico legal: Yes No
ii.If Injury due to

iv. Reported to Police: YesNo . Fir n

vi. If not reported lo police give reason

CLAIM DOCUMENTS sUBMITTED -CHECK LIST

Claim Form duly signed Investigation reports

Ornginal Pre-authorization request CT/MRUUSG/HPE investigation reports
Copy of the Pre-authorization approval letter Doctor's reference slip fordggF TOFULTISPECIALITY HOSPITA
SOCIETY,
Copy of photo ID card of patient verified by hospital ECG
A-1, JAYSHREE NARAYAN
Pharmacy blls SAMTA CHAR RASTA, S/BRAMPHRA,
Hospital Discharge Summary
MLC reports & Police FIR VADODARA.
PH. C 94049044
Operation Theatre notes

Hospital main bill

Original death summaryfrlielbsp e aiea0191
Reg. No. BI2T/690
Hospital break-up bill Any other, please specity

ADDITIONAL DETAILS IN CASE OF NON-NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital :

A-5ATSHREE |NAKAZA SOCIETY D
City: Y ADopARA 1 Slate lalR|A T 4
Pin Code: 9 o 2 2 b) Phone No.4 9 2 slo 6S3s0Rgistration No. with State Cod|
d) Hospital PAN; e) Number of Inpatient beds:
Facilities available in the hospital i.OT: No . ICU

ii) Others:
 BA
Dr. Ketan Patel
MD Pathologist
Diagnostic &Pathology
Reg. No.G-20476 ABOR ATORY

Patient's Name :MANUJ KUMAR Ref. No. 14083

Referred by :DR. AJIT GOHIL (MS, FMAS) Age 34 Years
Date :09/11/2021 14:13 Sex :Male

HEMOGRAM

Test Name Result Units Biological Reference Interval

Hemoglobin: 15.8 g/dl [13.0-18.0]

Total RBC Count: 5.03 mill/cmm 14.7-6.0]
Total WBC Count: 9400 /cmm [4000-10000]
Platelet Count 1.42 /cmm 1.5-4.5
BloodIndices
P.C.V 45.4 [42-52]
M.C.V. 90.26
M.C.H.
femtolitre (78-100
31.41 Pg (27-31]
M.C.H.C. 34.8 g/dl [32-36]
R.D.W. 13.1 [11.5-14.0
Differential WBC Count
Polymorphs 87 % [60 - 70]

Lymphocytes 11 (20-401
Eosinophils: 01 [-41
Monocytes 01 2-61
Basophils: 00 0-1]
PS For MP No any parasites seen.

Dr. Ketan Patel

MD Pathologist
Reg. No. G-20476

Working Hours: 800 am to 9.00 prm Sunday: 800 am to 1.00 Noon

Note: The above results
subject to
are variation due to technical limitation and hence correlation with clinical
findings and
investigations should be done.
FF-150, Gangotri Apartment, New Alkapuri Road, Gotri, Vadodara 390 021.
Mobile: 96623 24264 / 79900 95643
 GAL

O
Dr. Ketan Patel
MD Pathologist
Reg. No.G-20476 Sai Diagnostic &Pathology
ABORATORY

Patient's Name : MANUJ KUMAR Ref. No. 14083

Referred by DR. AJIT GOHIL (MS, FMAS) Age : 34 Years
Date 09/11/2021 14:15 Sex Male

BIOCHEMICALTESTS

Test Name Result Units Biologlcal Reference Interval

Randum Blood sugar 159 mg/dl 70 to 140

RandumUrine sugar Not given

S.G.P.T.
62 U/L 0- 40

G.R.P.Test 9.89 mg/L 0.0- 5.0O

(CReactive Protein
CREATININE
Test Name Result Inis Biological Reference Interval

Serum creatinine: 0.78 mg/dl 0.4-1.5

Estimated GFR MALE: 121.10 ml/min/1.73m [>60]

Dr. Ketan Patel

MD Pathologist
Reg. No. G-20476

Working Hours : 8 00 am to 9.00 pm Sunday: 800 am to 1.00 Noon

Note: The above results are subject to variation due to technical limitation and hence correlation with clinical findings and investigations should be done.

FF-150, Gangotri Apartment, New Alkapuri Road, Gotri, Vadodara 390 021.
Mobile: 96623 24264/ 79900
95643
 BAL

OD
Dr. Ketan Patel
MD Pathologist
Reg. No.G-20476
Sai Diagnostic& Pathology
ABORATORY

Ref. No. 14083

Patient's Name MANUJ KUMAR
Referred by DR. AJIT GOHIL (MS, FMAS) Age :34Years
Date 09/11/2021 14:15 Sex Male

Dengue Antigen
Test Name Result
Dengue NS1 Antigen POSITIVE

Dengue Antibodies (1gG &IgM)

Test Name Result

Dengue lgG: Negative

Dengue igM: Negative

While sample should be collected as soon as possible after onset of illness, it is

recommended that follow up of testing should be done on day 10 after the first
sample to allow seroconversion, especially when the test is negative and Dengue
virus infection is clinicaly suspected.

80% of the patients may have detectable levels of lgM antibody by day 5 of illness
and 99% by day 10.

IgM levels rise quickly and peak by two weeks after onset of symptoms and then
fall fo become undetectable over 2-3 months. IgG anfibodies rise quickly and peak
at about two weeks post infection and then decline slowly over 3-6 months.

Though screening test does provide evidence to distinguish the past (secondary)
infecfion from curent (primary) ongoing infection, a negative result does not
preclude the possibility of infection with Dengue virus.

Done By Immunocapture[EIA) or immunochromatography method

Dr. Ketan Patel

MD Pathologist
Reg. No. G-20476
Working Hours: 8.00 am to 9.00 pm Sunday:8.00 am to 1.00 Noon
Note: The above results
subject to variation due to technical limitation and hence correlation with clinical
are
findings and investigations should be done.
FF-150, Gangotri Apartment, New
Mobile: 96623
Alkapuri Road, Gotri, Vadodara- 390 021.
24264 /79900 95643
 BALA
Dr. Ketan Pate
MD Pathologist
Diagnostic &Pathology
OOReg. No.G-20476 .ABOR ATOR Y

Patient's Name MANUJ KUMAR Ref. No. 14083

Referred by :DR. AJIT GOHIL (MS , FMAS) Age 34 Years
Date 09/11/2021 14:13 Sex : Male

Chickungunya lgG/lgM
Method: Immunochromatography
Units Blologlcal Reference Interval
Test Name Result

Negative Desirable level/lowrisk:<

Chickungunya lgm:
200,Desirable level/low risk:< 200
Negative Desirable level/low risk:<
Chickungunya lgG:
200,Desirable level/low risk : <200

Dr. Ketan Patel

MD Pathologist
Reg. No. G-20476

Working Hours: 8.00 am to 9.00 pn Sunday: 8.00 am to 1 00 Noon

Note: The above results are subject to variation due to technical limitation and hence corelation with clinical findings and investigations should be done.

FF-150, Gangotri Apartment, New Alkapuri Road, Gotri, Vadodara 390 021.
Mobile: 96623 24264 / 79900 95643
SAI DAIGNOSTIC & PATHOLOGY LABORATORY
FF-150 Gangotri Appartment, Opp Bank of baroda, New Alkapuri vuda
Road, Gotri, Vadodara 21
MANUJ KUMAR Bill No.:4831
Date:09/11/2021
Reference No.:14083

Srl. Investigations/Services
Amount RsS.
1 CBC MP
300.00
2 RBS 100.00
3 CRP 300.00
4 CREATININE 200.00
5 SGPT 200.00
6 Dengue NS1 IgG,IgM 1,000.00
7 Chikungunya lgG/ lgM 1,200.00

Rupees Three Thousand Three.Hundred Bill Total: 3,300.00

Lab0rdioiy Total Paid:|
Onyi Diagnostics& Pathology 3,300.00
FF-150,0dri Complex,
Due 0.00
eda
Opp. banR
U
Road,
Road, Gotri
Alkapuri-Vud:
New
BaFor, SAP DAIGNOSTIC & PATHOLOGY LABORATORY
 A LAG

OO
Dr. Ketan Patel
MD Pathologist
Reg. No. G-20476
Sai Diagnostic &Pathology
LABOR ATOR Y

Patient's Name MANUJ KUMAR Ref. No. 14118

Referred by :DR. AJIT GOHIL (MS, FMAS) Age 34 Years
Date :11/11/2021 09:53 Sex Male

HEMOGRAM

Test Namne Result Units Biological Reference Interval

Hemoglobin: 13.8 g/dl [13.0-18.0

Total RBC Count: 4.50 mill/cmm [4.7-6.0]
Total WBC Count: 3600 /cmm [4000-10000]
Platelet Count: 0.44 cmm 1.5-4.5
Blood Indices
P.C.V 40.7 % [42-52]
M.C.V.: 90.44 femtolitre (78-100]
M.C.H. .67 Pg [27-31]
M.C.H.C. 33.9 g/dl [32-36]
R.D.W. 12.6 % [11.5-14.0]
Differential WBCCount [60 - 70]
Polymorphs: 88
Lymphocytes 10 [20-40]
Eosinophils: 01 % [-41
Monocytes: 01 2-61
Basophils: 00 % 0-11

BIOCHEMICALTESTS

Test Name Result Units Biological Reference Interval

C.R.P.Test 249 mg/L 0.0-5.0

(CReactive Protein

Dr. Ketan Patel

MD Pathologist
Reg. No. G-20476

Working Hours: 8.00 am to 9.00 pm Sunday :8.00 am to 1.00 Noon

Note: The above results are subject to variation due to technical limitation and hence correlation with clinical findings and investigations shouldbedone

FF-150, Gangotri Apartment, New AlkapuriRoad, Gotri, Vadodara -390 021.

Mobile: 96623 24264/79900 95643
 Sai Diagnostic& Pathology
LA BO RATORY
FF-150, Gangotri Apartment, New Alkapuri Road, Gotri
Vadodara- 390 021.Mobile : 9662324264, 9974176875
Working Hours: 8.00 am to 9.00 pm Dr. Ketan Patel
Sunday: 8.00 am to 1.00 Noon MD Pathologist

Name of
Patient's (Anuy kumay
Age Sex

Investigation: M13
1i2211

CB
C

ais siels des denly dendea

/ 1 u o , ioil>l uIÉNo2, *juesiyl ds, »îll, 4sleal. |
SAI DAIGNOSTIC & PATHOLOGY LABORATORY
FF-150 Gangotri Appartment, Opp Bank of baroda, New Alkapuri vuda
Road, Gotri, Vadodara 21
MANUJ KUMAR Bill No.: 4848
Date:11/11/2021
Reference No.: 14118

Srl. Investigations/Services Amount Rs.

1 CBC 250.00
2 CRP 300.00

Rupees Five Hundred Fifty Only Bill Total:| 550.00

Sai Diagnostics&Pathology LaboTptalyPaid: 550.00
FF-150,Gangotri Complex, Due 0.00
Opp. Barof Baroda,
NevAlkapuri-Vuda Road, Gotri Road,
For, S8 PAIGNOSTIC & PATHOLOGY LABORATORY
 SA

OO
Dr. Ketan Patel

Reg.
MD Pathologist
No. G-20476 Sai Diagnostic& Pathology
LABORATORY
Patient's Name : MANUJ KUMAR Ref. No. 14097
Referred by : DR. AJIT GOHIL(Ms, FMAS) Age 34 Years
Date : 10/11/2021 09:59 Sex Male

HEMOGRAM
Test Name Result Units Biological Reference Interval

Hemoglobin : 13.9 g/dl [13.0-18.0]

Total RBC Count: 4.49 mill/cmmm [4.7-6.0]
Total WBC Count: 7900 /cmm [4000-10000]
Platelet Count: 1.00 /cmm 1.5-4.5
Blood Indices
P.C.V 40.6 [42-52]
M.C.V. 90.42 femtolitre [78-100]
M.C.H.: 30.96 Pg [27-31]
M.C.H.C. 34.2 g/dl 32-36]
R.D.W. 12.9 % [11.5-14.0]
Differential WBC Count
Polymorphs 86 60 70]
Lymphocytes: 10 (20-401
Eosinophils: 02 [1-41
Monocytes 02 12-61
Basophils 00 % 0-11

BIOCHEMICALTESTSS

Test Name Result Units Biological Reference Interval

C.R.P.Test 26.4 mg/L 0.0-5.0

(CReactive Protein

Dr. Ketan Patel

MD Pathologist
Reg. No. G-20476

Working Hours : 8.00 am to 9.00 pm Sunday: 8 00 am to 1.00 Noon

Note: The above results are subject to variation due to technical limitation and hence corelation with clinical findings and investigations should bedone.

FF-150, Gangotri Apartment, New Alkapuri Road, Gotri, Vadodara -390 021.
Mobile: 96623 24264/7990095643
 Diagnostic &Patholog
ai LAB ORATORY
FF-150, Gangotri Apartment, New Alkapuri Road, Gotri
Vadodara 390 021. Mobile 9662324264
Working Hours : 8.00 am to 9.00 pm Dr. Ketan Patel
Sunday: 8.00 am to 1.00 Noon MD Pathologist

Name of Patient's MNU Komi

Age Sex-
lo-J1-21
investigation

CEe CRP

i s siepol2dls aies Yuieiy dRel

g/1u0, jonlall auiÉlo2, o uASIyl Às, »1>ll, qseR.
214 2144I2 i 2tGiqiR I9iRoil l-00 el 2iivoll G-00
2fqR 24q2 oil C-00 efl oul2oil 1-00 scis
SAI DAIGNOSTIC & PATHOLOGY LABORATORY
FF-150 Gangotri Appartment, Opp Bank of baroda, New Alkapuri vuda
Road, Gotri, Vadodara 21
MANUJ KUMAR Bill No.:4840
Date:10/11/2021
Reference No.:14097

Srl. Investigations/Services Amount Rs.

1 CBC 250.00
2 CRP 300.00

Rupees Five Hundred Fifty Only Bill Total:| 550.00

550.00
Sai Diagnostics &tholodotalPaido
Due: 0.00
FF-150.Gg1ori Complex,
Opp. BXhk Of Baroda,
For, $AI BAGNOSTIC&PATHoLd&y LABORATORY
 SAG AAROGYA PVT. LTD.
A-1, Jayshree Narayan Society,
Samata Char Rasta,
Subhanpura, Vadodara.
DAILY BILLING SHEET Tel.: (C) 0265-2386555
MULTISPECIALITY HOSPITAL Email:ajit_gohil@rediffmail.com
Patient's Name:_
Consulting Doctor: Date of Admission:
DAYS
DATE
DEPOSIT
ROOM CHARGE
VISITS
o_
DR.
DR.
DR.
DR.
Fluid Admn. Charge
IVAM/SC INJ.Admn. Charge
Nursing Charge
RBS
NEBULISATION
02
ECG
VENTILATOR
CASE FEE 66
DRESSING
CATHETER
SPO2
MONITORING
RT INSERTION
ENEMA
B.T.
AIRWATERBED
PHYSIOTHERAPY
I.I.T.V.
INSTRUMENT CHARGE
O.T.THEATRE CHARGES
OPERATIVE CHARGES
ANAESTHESIA
PATHOLOGY/LAB
DIETICIAN
CTSCAN X-RAY
OT DISPOSABLE
| HOSPITAL SUPPLY DRUGS
HOSPITAL SUPPLY MATERIAL
MISCELLANOUS

14,28
 A-1, Jayshree Narayan Soc.,
Samata Char Rasta, Subhanpura, Vadodara.
Tel. (C)0265-2386555, 6538555
Mob.:9925006535
Email: ajit gohil@rediffmail.com
MULTISPECIALITY HOSPITAL

O
ne Ma duma

Dnos) 1 Den
e LOPenig

C T h e n s ot a n p e

DlOnMoUe

n e r n 2 CuppeATVe_neert

iul2

1/11&
DV

D
Reg.
 INVESTIGATION SHEET
201 s*erling TPf E 10.4
Nep
ears
Nealitk. HapineE
Becante life matlern

Date
Time
Hb

TC
RSsO
DC
Hct
ESR
M.P.
Platelets

.
PT/INR

P.T.T.
.
Albumin
Sugar
Micro
RBS .

FBS
PP.BS
Na+
K+
CI
HCO
A/G
Urea

Creatinine
Osmolality
Tot. Proteins
Albumin
Globulin
Alg Ratio
Bilirubin
SGOT
SGPT

ALKPO
CPK

CPK-MB
LDH1
CRITICAL VALUE/RESULT

INFORMEDBY
COMMUNICATED TO
SH/129/74(00/00/2005)
 A-1, Jayshree Narayan Soc.,
Samta Char Rasta, Subhanpura, Vadodara.
Tel.: (C) 0265 -2386555, 8460001971
M:9925006535
MULTISPECIALITY HOSPITAL Email:ajit_gohil@rediffmail.com

Daté

PEG
 SATYAM E I
B/3/4,AAKAR COPFLEX, SANTA CHAR RASTA,SATA Phone:
aaaandosaesasstsessneaeagamamseskunsesete

Dr.Naae DR. AJIT GOHIL BILL OF SUPPLY Bil1No 1983

Patient FANLUKLAR Date : 10/11/21
Address
&ty Product FG Pak Batcha Exp RP GST G Amt Aount
1/0 FREEGO FEG SYFP ALEM 1K200 MLAN0616003 04/23 337.50 12.0 36.16 337.50

DL No.G-VAD-181745 GJ-VA-181746 Total 301.34

ST ND 24AEHFTBI3OR1ZT,T:30/12/99 Gst 36.16
E.&0.E. Subject to VADODARA Jurisdicaticn Disc Amt 0.00
Grand Tntal T8.00
 To Sai Diagnostic And Pathology Laboratory
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To Sai Diagnostic And Pathology Laboratory

3,850.00 550.00
Completed Nov 10, 1143 AM Completed Nov 11, 8A2 AM

UUnion Bank of India XXXXXXS897 Union Bank of India XXXXXX5897

UPI transaction iD UPI Uransactlon ID

131446342726
To: Sai Diagnostic And Pathology Laboratory
paytma12810050S0101ccvn6i19z696@paytm
From: MANUJ KUMAR (Union Bank of India)
manuj banker 1@okhdicbank
Google transaction 1D
13155855835s1
To: Sei Dlagnostic And Pathology Luboretory
paytmqr281005050 101 cevnolf9z6g0@paytm
From: MANUJ KUMAR (Union Bank of India)
manuj banker 1@okhdfcbank
Google transection ID

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GPay G Pay

To SAG AARoGYA PRIVATE UMITED

14,281.00

Bel p Rs 338
verified Merchant

Competed- Nov 11, 752 PM

U Union Bsnkot India X X x s 8 9 7

Payment started
Payment eceved by SAS AAROEYA PRiVATE
DTED

Purchdae confirmed

Ter SAG AAROSYA PRiVATE LIMITED

segaorDgya750Derodampey

From MANuJ KUMAR (Uoion Benk ol Indie)

manibarker 1éokhatchank

Gocgie transacion
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GPay