OPD CLAIM FORM

Issuance of this fom does not amount to adnission of any iabity cf under the policy on the part of the Insurers
Piease give the following snformation correcty and completely to enable us process your ciaim prompty
All dates to be entered as Date /Month Year

Type of Claim: Doctor Consultation M Dental Vision

Prescribed diagnosis Heath Check-Up
Prescribed Medicines 1WHO approved vaccinations

Corporate Name
2 Policy Number (in Fuil)
3 Employee Number
4 Name of the Employee
Emplayee Code
Circle
Details of the Patent
(In respect of whom cla1m is made)
(a)Name & Relatonshp with the Insured VANURA DHtAi
(b)Present Completed Age

5 Nature of Disease contracted Aient

Suffered or injury sustained (Optional)

7
6 Date on which injuy was sustaned Disease
Or ailment first detected (Optional)
Name and Address of the attending
69-2o3
Medicai Pract1toner
Location
tanay

Details of Expenses ( Supports annexed) No of Bills Total

Consultation Fees (Consultaton note to be
attached)
2 Medicines

3 Tests X-rays ECG etc HALSCan.

4 Visiting fees

5 Others

Grand Total :Rs

DECLARATION

respect and agree that if | have

Ihereby warrant the truth of the foregoing particulars in every concealment of any fact, my right to
suppression or
made or shall make any false or untrue statement. declare that, in respect
forfeited. I further
claim reimbursement of the said expenses shall be absolutely
 of the above treatment, no benefits are availed or claimed under any other Medical Scheme or
Insurance.

IALSO CcONSENT AND AUTHORISE CARE HEALTH INSURANCE LTD &THIRD PARTY
ADMINISTRATOR TO SEEK MEDICAL INFORMATION FROM ANY HOSPITAL I MEDICAL
PRACTITIONER WHO HAS AT ANY TIME ATTENDED ON ME.

I also authorize TPA to receive payment from the insurance company as reimbursement of hospital bills
incurred on my / the insured person's treatment.

Date:
Place: lenmi

Signature of the Claimant

|. DR.
Dt6-3.2
Skans
3.
/6-4--3

Br. Aoo
 SUNDARAM
Dr. A. SHANMUGA Phd (Sports Med)
M.S (Otho) Mch (Ortho) Surgeon
Senior Consultant Orthopaedic ADYAR ORTHO CLINIC
Reg No:57033
Visiting Consullant:
ADYAR ORTHO CLINIC JCHENNAI CHENNAIMEENAKSHI
MEENAKSH0 MULTISPECIALITY HOSPITAL Apollo Spectra s Fortis
Kamaraj Avenue
108/2, Akhil Apartment, No.149/70, Luz Church Road. Apollo Spectra Hospitals Fortis Malar Hospital
Poppat lamals),
2nd Street, (Near Mylapore, Chennai - 600 004. No 41/42, Sathyadev Avenue, No.52, First Main Road, Gandhi Nagar,
Chennai - 600 020.
Adyar, Ph: 044- 42 938 938 MRC Nagar, R.A. Puram, Adyar, Chennai - 600 020
67744 / 99400 43000
044 - 2441 0000/ 99626 (Time: 4.30 pm to 5.30 pm) Chennai -28. Ph:044 - 6868 2000 Ph:99625 99933 / 044 - 49334933
6.00 pm to 8.00 pm
Time :10.00 am to 1.00 pm &

+91-9789017625 06-09-2023
43y8m,F
ANURADHA MRS (#AOC123025),
NEURALGIA
C4 C5 / C5C6 DISCPROLAPSE WITH LEFT BRACHIAL
Diagnosis

B
Duration Dosagcs Instructions
Medicinc Namc

15 1-0-1 Before
TABLET RAB-S (20 mg) food
day(s)

15 0-0-1 After food

CAPSULECAL OMEGA K2
Folic acid, Cyanocobalamin & Vitamin K2-7 Softgel day(s)
Calcium Citratc Malate,Omcga 3 Fatty Acid ( EPA&DHA), Calcitriol,

15 0 -0- 1 After food

TABLET FITAXO (75mg+1Omg )
PREGABALIN+NORTRIPTYLINE day(s)

15 0-0-1 After food

TABLET OWEL FORTE
ACID,MIXED CAROTENE,CALCIUM day(s)
UBIDECARENONE( CO-ENZYME Q10 ),LYCOPENE,OMEGA 3 FATTY
ASCORBATE, WVHEAT GERM OIL & VITAMIN B12

15 1-0-1 After food

TABLET DNEC-SR+ (100+325+15 mg)
Accclofcnac, Paracctamol & Serratiopecptidase day(s)

15 1 -0-1 After food

TABLET THIOMIN (4 mg)
THIOCOLCHICOSIDE day(s)

Dr. A.SHANMUGA SUNDARAM

MS (Ortho) Mch (Ortho) Ph.D
RegNo: 57033
 GEMINI
Advanced PET CT &MRI Scan
Aminiikarai Vadapalani Mogappair Ambattur Adyar
1236,Golden (olony First Street, 470,MTH Road, Plot 133, Kosturibai Mugar
High Road, 47,100 feet Road,
Pooncmallee First Cross Street, Adya,
5$15,
Opp. Skywaik, Aminjikarai, Neot Laxman Shruthi Signal, Anna Nagar West Extn. Mogappoi, Suroswathi Noga, Titumullaivoyal, Chennoi 600 020.
Chennai - 600026, (hennai -600 050, Ambattu, Chennai -600 053.
Chennoi - 600 029. Ph:98848 15149 Ph: 9884815070
Ph:98848 IS140 Ph: 98848 15199, 98848 1519%
Ph:98848 15185 Ph:98848 15198 Ph: 9884815075
Ph:9884194436 Ph: 98848 1S147

Patient Name Age..

Ref. Dr. :

Address:

Ph. No.
INVESTIGATION REQUIRED:
PET CT
WHOLE BODY PET

F18 BONE SCAN

PSMA

DOTA NOC

1.5T MRI

MULTISLICE CT CLINICA DETAILS

USG
COLOUR DOPPLER
DIGITAL MAMMOGRAPHY

LAB

TMT /ECG/EEG/ ECHO

DEXA SCAN

Dr. A. SHANMU r ARAM

K.SIVA MS (Ortho) Mch,(ori) Pyo
9840997373 Reg No:7033
PT.0.
 GEMINI sCANS
Name Mrs.Anuradha
Age/sex 44Y/F
Id.No. ADY23/2348
Date D6.09.2023
Ref.By Dr.A.Shanmuga Sundaram,MS(Drtho).Mch(Drtho)., Ph.D.
MRI Study of Cervical Spine
Technique T2W Sagittal> Whale Spine Screening
TIH, ZW Sagittal MR Myelogram
12me 20Aial

Loss of cervical lardosis. No evidence af subluxation / dislocation.

C4-C5 disc shows mild posterior bulge causing thecal sac indentation. No evidence of neural faraminal
narrowing/ nerve root compression.
C5-C6 disc shaws posteriar bulge with postero-central protrusion causing thecal sac compression. Na
evidence of neural foraminal narrawing/ nerve root compression.
The vertebral bodies, pedicles, laminae, transverse processes appear normal.
The uncovertebral joints andneural foraminae appear narmal.
The cervical canal dimensions from C2 to C7 levels
Level C2-C3 C3-C4 C4-C5 C5-C6 C6-C7 C7-D1
I0.8 I0.2 I1.5 I.0 |1.5

The cervical spinal cord and the CSF appear normal.

The cranio vertebral junction is normal. The atlanto-axial joints are normal.
Ihe pre and paraspinal regions appear normal.
Whole Spine Screening
No significant abnormality is visualized in the dorsal spine.
Sacralization of 5th umbar vertebral body seen.
[4-L5 disc shows posterior bulge causing thecal sac indentation. No evidence of neural foraminal narrowing/
nerve ro0t compression

Impression:
Loss of cervical lordosis. No evidence of subluxation / dislocation.
C4-C5 disc shows mild posterior bulge causing thecal sac indentation. No evidence of neural
foraminal narrowing/ nerve root compression.
C5-CG disc shows pasterior bulge with postera-central pratrusion causing thecal sa.
compressian. No evidence of neural faraminal narrowing/ nerve raat compression.
Cervical cord shows normal signals.

Dr.V.Ramkumar DMRD,DNB.
Consultant Radiolagist.
 GEMINI SCANS PVT. LTD., No. 133, Kasthuribai Nagar, 1st Cross Street, Adyar,
Chennai - 600 020. PH :9884815070, 9884815075
CASH RECEIPT
Bill No : 1191 Bill Date : 6/9/2023
Patient Name : Mrs. ANURADHA .V Age : 44 Y/F

Doctor Name : Dr. A.SHANMUGA SUNDARAM

SI No Modality Type Modality Name Amount

1 MRI CERVICAL SPINE 4,500.00

Total Amount : 4500.00

Amount in words : Four Thousand Five Hundred Only

Signature
 ABIRAMJ PHARMACY CASH BILL ao`.108/2, sl AuTtÜanasL
108/2, Akhil Apartment, Kamaraj Avenue D.L.NO. :3235/MII/20
2nd Street, (Near Poppat Jamals),. 3239/MII/21
20.
Adyar, Chennai - 600 020. GST NO.:33AUOPP4975F1Z6 DLITt, Q5siT GD QT -
044- 2441 0000/99626 67744/99496 45°00
Bill No. :
Name :
Date
Address :
Doctor::
BATCH EXP AMOUNT
QTY PACK PRODUCT
324.50 Acce
Accepted
25.
are
are Cards
Cards
Credi
Credit
Major
Major
\AII
AIl

within 10 daystrom biltdate

Rates äre inctusive of alt Taxes / E&O.E Return Policy:Only full strips wilbe takenback,
 ADYAR ORTHO CLINIC
TOTAL EURE C.D. PHYSIOTHERAPY CLINIC
New No. 108/2, Old No. 77, Akil
Apartment,
Kamaraj Avenue, 2nd Street, Adyar, Chennai - 600 020.
Mobile :+91 98844 71144, 94443 88665
No. : Date :
818
Patient Name :
Address:
Amudha
Modalities:

Amount Signature
 RTHO CLINIC
Certified)
partment, Kamaraj Avenue 2nd Street. Bill No :
Jat Jamals), Adyar, Chennai -600 020.
441 0000/99626 67744 / 99400 43000 A0CCO03474
Date :06/09/2023
A.YAA NTH0 CLN
Patient :MRS.ANURADHA
S.No
Particulars DR.A.SHANMUGASUNDARAM MS(ORTHO) Mch,PhD.
Amount

Add CONSULTATION
600 00

GRAND TOTAL 600.00

Card Accepted For ADY CLINIC