tn iM o.*d snEg{, Wd 3qqool qft qn .

r{ drfrs t fl-{ cr6 s} fAC ilsTvruoronrunee trloiltHs FFOta THE O TE OF lSSnrE

SHAHPORE, SURAT, SuraF395OO3

ElflEtBllTitfh RTGS / NEFT IFSC CODE : BARBGillllSuR
c&9
ifrtq qrdr sAvrNGs Ac@t NT
YYY
Pay or Bearer
qI EIT*T
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erar o't
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5
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14870100015185
n

VIPULBHAI PRABHUBI.IAI PARMAR

KIRANBHAI PBABHUBHAI PARMAH
sBz012/lrF
rnra * grfr rrsrsil qr qqga c{ tq
SHP Plas slgn abow
Payable at par at all branches in lndia

rtOOOOElil lq50ItOIEr! OI5IE5'!' It

 D

MIP-CTS VI.$ r rp
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172.29.14.221j ' #am*: ?ej*u*"r F*t*l t L**mti*m : JL$"{ffiffiSA*&# *nsurail** *c : Nati*n*$ *x"rs**ract*e ffimre}#* ffi.# Ch*ng* E**ssrrvs}r*
m Policy Entry
6 Pre Authorization lnt Oate From lnt Date To
g BillProcessing
*ir:
B Transa*ti*rr
lntimation (Other)
Document Receive And Filiing
eeF* s**lcy *tr*rrrth*r Smrd {t* Xmsa*red Fle$I# In* Type *cti*r:
Generate Claim Query
Update Claim Query
Upload Doc Tagging
HH7S2400499 21a512023 31 060050221 0003821 HHS7.0900825085 MAAN Reimbursement BffiTd
g R*p*ns
g Front Desk lnsured Name MAAN lssuing Office SURAT DO I
g MIS Address A- 27, SOHAM APARTMENT 3A1, MANGAL Area
H Documents GROUP SOCIETY, Sunat, Surat, Gujarat, India
State

City

Pin 395004 Phone 9978276578

Email lD Employee lD

lntimator Name MAAN Req

lllness Hospital
fi*evusx t.c.u. and [,tulTt sPEctLtTy
HOSPITAL
Likely DOA o21o512023 Likely DOD

lntimation Type Reimbursement v tntimation Mode Phone w

lntimation Date o210512023 lntimation'[ime 2v 24w PMw
lns.Co. Claim No Web lntimation No.

Admission Type : Emergency \2 Glear

CCN HH7S2400499
 MEDICAL OFFICER REVIEW SHEET

)iqil i t;71: f4 llll ! tl

,ollcy Type lauond Failyar tedlclalm Pollcy

r(vE) Req.Date

Policy Prc Existing

,ationfs Exclusion

CLAIII HISTORY
iccN s{ETllTl I.T EI'IN PA Date PAAmnt ?TEftIfi!

HH7923056 Chim ACUTE 24/06n023

67 Closed/R VIRAL
ejected

Room Rent
Dlsc.
Doctor Digc. ted
Dlsc.
Fesr Lab Chg
Dlsc.
OTDirc. irotat m Remarks
iDIsc.
I
0.00 0ftli 0.00 0.001 0.00

No E!]l] Erp.lhrd
(Rt.,
Grcrr rnfl:iTl] il u
Amount(R .)

m
(3) 0210fj1,2u23 Medldncs by 91A.00
1 0124.00 0.00

(4) 02105t2023 lrw€sligation I 920.00 9a).00 0.00

Reason:

58s (s) ConsulLnt t 600.00 FIX.]

Rearon:

11r (r) Room R€nt

Rearon:

111 (r) I 2500.00 [nt]

Reason:

111 (1) 1 0.q) 1250.00 Fro

Rearon:

't1111 Prcfessixul 1
d'glge
". .
 MEDICAL OFFICER REVIEW SHEET
Rcaron:
i

:t11r l1l t0/}lffitzo2l Ofter Regbhatlon , 1 0.00 200.00 0.q,

Epenses
Realon:
I
il 11 (1) Oher Dnsslngs I 700.00 700.00 0.00 7(x).00 0.q)
Reason:

111 (r) ui06n023 OT Rebbd Charycr I 3004.(x) 3064.m 0.00 0.00 3664.00 0.q)
Charyer

11r (1) ut05/2tB lnvestgalion PR@EDt,R 9161.00 9161.00 0.00 9161.00

g& 0.00
ES
Prcceduras
Rcaron:

246(21 o4/0s2023 M6dkin€8 irt€dldn€c by 1 4G56.00 0.00

't056.(x) 0.q)

Reaaon:

Sub 0J0 39875.00 0.00 0.00

Poat Bill
w7 Proftsslonel CorlsultrEnt 1 I 1 0.00
(121 0.q)
drarg8s
Rcaton:

io6/os/2o23 iredldnos Modldn€8 by I 0.fl) 4s2.00 0.00

(13)
Reason:

08/05/2023 Mediines by I 745.00 0.00 745.00 0.q)

(r1 o8/052(m Pto{brsktnal Comullant I ll 0.00 0.00 'l 0.00

Rearon:

1/ujn023 iiledkln€3 Medkin€s by 1 460.00 460.00 0.(n /160.00 0.q)

Rcason:

631 (e) 11t05t20i23 M€didnos Itrledkircs by I

1 1100.00 0.00 I 0.q,
Rearon:

308 (6) 16/052023 Medldnss by i .052.00

0.q)
Shop
Reason:

636 (7) 16t05t2fft3 Oher Drareings I I

1 0.q) 1 0.q)

Reason:

Sub 0509.00 0.00 6509.00 0.00

463E4.00 0.00 463E4.00 0.00

Copaynent 0.q)

Dlrcount 0

Payabh Amount 0.00

 Any Speclal or Addlonal Notes For Thls parflcular Clalmllnsurcd :

ICD INFORIIATION

,lCD Levet i Gode irName

I ,, J

Pre PostGhimed

6509.00 of 100000.00 = 6.517o

some rmDortant sDecial conditions for National parirmr Mediclaim policx,

Clalm :Admlslble ilax Payable !nf,rocess Payable ln

Claim(Rs.)
and Nursing 4500.(x) 0.00 0.00 o.ool 0.00 0.(x),

Surgeon, Anesthesist, 9750.00 0.00 0.00 0.00 0.00 0.00

Medical
Prac{itioner, Consultianb
Special fees
Charges 32134.00 0.00 0.00 0.00 0.00 0.00
,Other

Expenditurc Cost Percentage

Room SeMces

Professional dnrges .O2Yo

Medicines

lnvestigations 1.98%

Other Expenses 4.310h

lnvestigations & Pocedures 19.75%

OT Related Charyes .90%

 CLAIM FORM - PART B

H
H€RII'AGE HEAL'IH
TO BE FILLED IN BY THE HOSPITAL
The issue of this Fom is nol to be laken as an admission of liability
Please include the original preaulhorization request Fom in lieu of PART A
IRDAI License No. 008 (To be filled in block letters)
DETAILS OF HOSPITAL

a) Name of the Hospital :

o
b) Hospital lD : c) Type of Hospital : Network l-l Non Network network fill section E) m
o
-t
d) Name of the treating doctor o
z
e) Qualification : f) Registration No. with Slate Code: g) Phone

DETAILS OF THE PATIENT ADMITTED

a) Name of the patient :

b) lP Registration Number : c) Gender : Male o) ase: vearffil.uonths FTr.{ a) Date of

f) Date ot Admission

j) Type of Admission
: g) Time:
EEl@h'r
l,late.iry
Date ot Discharge:

Matmiry i) Dare of oelivcry:

i) Time
m @
m
o
:
J-l k) ir ii) GGvida Status: _--t
o
z
l) Stalus at time of discharge Oischarge to home oischargetoanotherhosnital
! Deceased
! m)Totalclaimedamornt [T-rI-Tl @

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

ICD 10 Codes Description

,{ a) b) ICD 1O PCS

i. Primary Oiagnosis i. Prcedure 1 :

)ai
ii. Additional Diagnosis ii. Procedure 2 :

iii. Co-morbidities iii. Procedure 3 :

iv. Co-morbidities iv. Details of Procsdurs

@
m
o
{
: !Yes nruo d) Pre-authorization Nurber o
c)Pre-authorizationoUtaineO :
z
o
e) lf authorization by network hospital nol obtained, give reason:

f)Hospitalizationduetoinjury: l-lVes !xe i.ifYes,givecause Setf-inflicted RoadTmfficAcciUentf| Substanceabuse/alcohol consumprionI

!
ii. lf lnjury due to Substance abuse/al@hol @nsumption, Test Conducted to establish this:
EY€s l-l No (lf Yes, attach reports) iii. lf Medico leg"t, J-l V"" [l lrlo

iv. Reported to Police

!v"" [ ruo r. fir no.
' '
vi. lf nol reporled to police give reason

CLAIM DOCUMENTS SUBMITTED . CHECK LIST

Form duly signed

[],,.-truestigationreports
Original Pre-auhorization request l-l CfftlnUUsOnrPE investigation reporls
a
Copy of the Pre-authorization approval letler
[fD-iao,'" *t"r"ne slip for investigation m
o
ot photo lO card of patient verified by hospital
[frcc -t
o
z
Hospital Oischarge Summary
ff-en^r^ "v
bills
o
p6i-eration Theatre notes
tr MLC repo(s & Police FIR
-\
:: /
fr/Hospital mainbilt
tr Original dealh summary frcm hospital where applicable

break-uo bill Any orher, please specily

l-ffosoital I
AODITIONAL DETAILS IN CASE OF NON.NETWORK HOSPITAL (ONLY FILL IN CASE OF NON.NETWORK HOSPITAL)

a) Address of the Hospital

City State

Pin Code : b) Phone No.: c) Registration No. with Slate

d) Hospital PAN e) Number of lnpatient beds: mTsI

f) Facililies available in the hospital: i. oT: ii. rcu: [v". [ft-.-= m
iii) Others

DECLARATION BY THE HOSPITAL READ VERY

We hereby declare that the intormation furnished this Claim Form is true & corect to the best of our knowledge & beliet statemenl,
suppression or mncealment of any malerial fact, ilr righl to claim under lhis claim shall be forfieted
a
m
o
Dare: W@ry q
6
z
a

Place : Signature and Seal ofthe Hospital Authority I

 GUIDANCE FOR FILLING CLAIM FORM - PART B (To be rilled in by the hospital)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A. DETAILS OF HOSPITAL

a) Name of Hospital Enler the name of hospital Name of hospital in full

b) Hospital lD Enter lD number of hospital As allocated by the TPA

c) Type of Hospital lndicate whether in network or non network hospital Tick the right option

d) Name of treating doctor Enter the name of the treatinq doctor Name of doctor in full

e) Qualilication Enter the qualifications of the treating doctor Abbreviations of educational qualifi cations

0 Registration No. with State Code Enter the registration number of the doctor along with As allocated by the Medical Council
the slate code of lndia
s) Phone No. Enter the phone number of doctor lnclude STD code with teleDhone number

SECTION B - DETAILS OF THE PATIENT ADMITTED

a) Name of Patient Enter the name of patient Name of hospital in full

b) lP Registration Number Enter Insurance provider registration number As allotted by the insurance provider

c) Gender lndicate Gender of the patient Tick Male or Female

d) Ase Enter age of the patient Number of years and months
e) Date of Birth Enter date of birlh Use dd-mm-yy format

0 Date of Admission Enter dale of admission Use dd-mm-yy fomal

g) Time Use hh-mm format

h) Date of Discharqe Enter date of discharge Use dd-mm-yy format

i) Time Enter time of discharoe Use hh-mm format

i) Type of Admission lndicate tvpe of admission of palient Tick the rioht oDtion

k) lf Matemity
Date of Delivery Enter Date of Oelivery it maternitv User dd-mm-yy format

Gravide Status Enter Gravida status if maternity use standard format

l) Status at time of discharge lndicate status of patient at time of discharge Tick the right option

m) Total claimed amount ln rupees (Do not enter paise values)

SECTION C. DETAILS OF THE AILMENT OIAGNOSED (PRIMARY)

a) ICD 10 Code

Primary Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
primary diagnosis

Additional Diagnosis Enter the ICD 10 Code and description of the Standard Fomat and Open text
additional diagnosis
Co-morbidities Enter the ICD '10 Code and description of the co-morbidites Standard Format and Open text
b) rcD 10 Pcs
Procedure 'l Enter the ICD 10 PCS and description of the first procedure Standard Format and Open lext
Procedure 2 Enter the ICD 10 PCS and description of lhe second procedure Standard Fomat and Open lext
Procedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Fomat and Open text
Details of Procedure Enter the details of the procedure Open texl

c) Pre-authorization obtained lndicate whether pre-authorization obtained Tick Yes or No

Enler pre-authorization number As allotted by TPA

Enler reason for not obtaining pre-authorization number Open text

not obtained, give reason

Q Hospitalization due to iniury lndi6te if hospitalization is due to injury Tick Yes or No

Cause lndicate cause of iniury Tick the right option

lf injury due to substance abuse/alcohol lndicate whether test conducted Tick Yes or No
consumption, test conducted to establish this

Medico Legal lndicate whether injury is medico legal Tick Yes or No

Reported To Police lndicate whether police report was filed Tick Yes or No

FIR No. Enter first information report number As issued by police authorities

lf not reported to police, give reason Enter reason for not reporting to police Open text

SECTION D. CLAIM DOCUMENTS SUBMITTED-CHECK LIST

lndicate which supporling documents are submitted

SEGTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address Enter the full postal address lnclude Street, City and Pin Code
b) Phone No. Enter the phone number of hospital lnclude STD code with telephone number
c) Registration No. with State Code Enter the registration number of the doctor along with As allo€ted by the Medical Council o, lndia
lhe state @de

d) Hospital PAN Enter lhe permanent account number As allotted by the ln@me Tax deparlment

e) Number of lnpatient beds Enter the number of inpatient beds Digils

0 Facilities availablg in the hospital lndicate facilities available in the hospital Tick the right oplion, lf othe6, please speciry

SECTION F . DECLARATION BY THE HOSPITAL

Read declaralion carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
 I_fl
tt
CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVELAND PERSONAL ACCIDENT - PART A
TO BE FILLED IN BY THE INSUREO

ttt
frEmffiEArr;
The issue ofthis Form is not to be taken as an admission of liability

IRDAI License No.008

(To be filled in block letters)
DETAILS OF PRIMARY INSIJRED:

a) Policy No: b) Sl. No./Certificate No:

c) Company/TPA lD No:
(t
m
o
-l
d) Name :
o
e)Address z

City State

Pin Code : Phone No Email lD

DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim/Heallh insurance: Yes No b) Date of commencement of first insurance wilhout break:

Policy a
m
d) Have you been hospitalized in the last four years since inceplion of lhe @ntract ? Yes No
o
Sum lnsured (Rs.) _{
o
z
Diagnosis : e) Previously covered by any other Mediclaim/Heahh lnsurance: Yes
E
f) lf yes, Company Name

OETAILS OF INSURED PERSON HOSPITAI.IZED:

n a. Name

b) Gender
:

c)Age: Years d) Date of Birth :

e) Relationship to Primary lnsured: Self Spouse

n chitd Other
D (Please Specify) a
m
o
f) Occupation: seruice l-l Ser Other
tr IPlease Soecifvl
o
=
z
1
g)Address (if diflerent from above)
o

City State

Pin Code Phone No Email lD

DETAILS OF HOSPITALEANON:

a) Name of Hospital where Admitted

b) Room Calegory omupied : Day cre single occupancy Twin sharing 3 or more beds per room

c) Hospitatization due to: lniury lllness Matemity d) Oate of injury/Date Disease firsl detected/Date of Delivery a
m
e) Date ofAddmission 0lime g) Date of Discharge h) lime :
Ioo
i) lf injury give cause : Self inficted Road Tramc Accident Subslance Abude /Alcohol Consumption i) It Medico legal:
Iv"" z
o
ii)Reported to police, llv". No iii) MLC Report & Police FIR attached
!v"" llro j) System ot Medicine

DETAILS OF CLAIM

a) Oetails of the treatment expenses daimed Claim Oocuments Submitted - Check List

i. PrFHospitalization Expenses : Rs. n. Claim Form Duly signed

iii. Post-Hospitalization Expenses : Rs. Copy of the claim intimation, if any

v. Ambulance Charces : Rs. Hospital Main Bill o

m
Hospital Break-up Bill o
+
Hospital Bill Payment Receipl o
vii. Pre-Hospitalizalion period Days z
m
Hospital Discharge Summary

b) claim for Domiciliary Hospitalization : Pharmacy Bill

Operalion Theatre Notes

c) Details of Lump sum / cash benefit claimed: ECG

i. Hospital Daily Cash Rs. Rs. Doctor's request lor investigation ^

iii- Crili€l illness Benefit: Rs. Rs. lnvestigation Repsts (induding CT/MRruSG/HPE)

v. Pre/Post Hospitlaization Trn Rs. Ooctor's Prescriplions

Lump sum benefit Rs. Total Rs. Others

DETAILS OF BILLS ENCLOSED:

sL. No. BillNo. Date lssued bv Towards

1 HosDital Main Bill

2 Pre-hosoitalizationBill: Nos.

3 Post-hosoitalizationBill: Nos.
4 Pharmacv Bills
5
a
m
o Ioo
7 z
I T
8
I
10

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT :

a) PAN b)Ac@unt Number: a

m

c) Bank Name and Branch : Ioo

d) Cheque/oo Payable details e) IFSC Code: z
o
(IMPORTANT:PLEASE TURN OVER)
DECLARATION BYTHE INSTJRED:

I hereby declare thatthe infomation furnished in this claim form is tre & corect to the besl ofmy knowledge and belief. lf I have made anyfalse or untrue statement, suppression
or a
concealment of any malerial fact with respect to questions asked in relation to lhis claim, my right to claim reimbuEement shaf be forfeited. I also consent & authorise m
TPA,/lnsurance company, to seek necessary medical inlormation /documents trom any hospital / Medical PEctitionerwho has atlended on the peBon againstwhm this claim is o
I
o
claim, if any z
I

r-Gse, ml L tL-
Date : Place Signature of th6 lnsured

GUIOANCE FOR FILLING CLAIM FORM - PART A (Io be tilled in by rhe insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A. DETAILS OF PRIMARY INSURED
a) Policy No. Enter lhe policy number As allotted by the insurance company
b) Sl. No./Certificate No. Enter the social insuEnce number of the cerlifi€te As allotted by the organization
number of social health insumnce scheme
c) Company TPA lD No. Enter the TPA lO No. License number as allotted by IRDA and
printed in TPA documents
d) Name Sumame, FiEl name, Middle name
e) Address Enter the full postal address lnclude street. Cilv and Pin Code
SECTION B. DETAILS OF INSURANCE HISTOMT
a) Curently covered by any other lndicate whether curently overed by another Tick Yes or No
Mediclaim / Health lnsurance? Medicliam / Health lnsurance
b) Date of Commencement of lirst insurance without break Enter lhe date of commenement oflirst insulan@ Use dd.mm-yy fomat
c) Company Name Enter lhe full name ot the insurane comDanv Name of lhe orqanization in full
Policy No Enter the policy number As allotted by the insurance @mpany
Sum lnsured Enter the total sum insured as per the policy ln rupees
d) Have you been Hospilalized in the last four yea6 since lndiBte whether hospitalized in the last tour yeaE Tick Yes or No
ineotion of the contract?
Date Enter the date of hospitalization User mrw format
Diagnosis Enter lhe diaonosis details Open Text
e) Previously Covered by any other lndiBte whether previously covered by anoth€r Tick Yes or No
Mediclaim / Health lnsurance? mediclaim / Health lnsuran@
0 CompanyName Enler lhe full name of the insurance mmDanv Name ofthe orqanization in full
SECTION C. DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Sumame, First name, Middle name
b) Gender Tick Male or Female
c) Age Enter aoe of the oalient Number of years and months
d) Date of Birth Enter Date of Birth o, balient Use dd-mm-w format
e) RelationshiD to Drimary lnsured lndicate relatidhshiD of halicnl wilh noli.rhdldet Tick ths rioht oDtion. if others. Dlease sDecifv
n OccuDation lndi@te occuDation of oalient Tick the rioht ootion. if otheE. Dlease sDecitu
o) Address lnclude slreet. Citv and Pin Code
h) Phone No Enter the phone number of Datient lnclude STD code with teleDhone number
i) E-mail lD ComDlete *mail address
SECTION D . DETAILS OF HOSPITALIZATION
a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full
b) Room category occupied lndiGte the room caleoory occuoied Tick the rioht option
c) Hospitalization due to lndi@te reason of hosoitaliztion Tick the riqht oDtion
d) Date ol lnjury / Date Disease lirst detected Enter the relevant date Use dd-mm-yy format
/ oate of Delivery
e) Oate of admission Enter date of admission Use dd-mm-yy format
0 Time Enter time of admission [Jse hh:mm format
o) Oate of discharoe Enter date of discharoe L,se dd-mm-w fomat
h) Time Enter time of discharod Use hh:mm format
i) lrinjurygivecause lndiete €use of injury Tick the righl option
It Medico legal lndicate whether injury in medico legal lick Yes or No
Reported to Police lndicate whether police reporl was filed fick Yes or No
MLC ReDorl & Polic€ FIR attached lndi€te whether MLC report and Polie FIR atlacied Tick Yes or No
il Svslem ol Medicine Enler the svstem of medicine followed in tEalino the Datient Oben Texl
SECTION E . DETAILS OF CLAIM
a) Oetails ofTreatment Exoenses ln rupees (Do not enter paise values)
b) Claim for Domiciliarv Hospitalization Tick Yes or No
c) Oetails of Lumo sum/€sh benefit claimed Enter the amount claimed as ftrmn crm ,.a<h henFfit ln ruDees (Do not enter oaise valuesl
d) Claim Dodmehts Submitted-Check List lndiBte which suDDortino douments are submitled
SECTION F . DETAILS OF BILLS ENCLOSED

SECTION G . DETAILS OF PRIMARY INSURED'S EANKACCOUNT

A) PAN Enter lhe. permanent a@ount number As allotted by the lnmme Tax deDartment
b) Acmunt Number As allotted by the bank
c) Bank Name and Branch
d) Cheque/DD payable details Enter the name of beneficiary the cheque/ Name of the individual/organization in full
DO should be made out to
e) IFSC Code IFSC code of the bank branch in ,ull
SECTION H - DECLARATION BY THE INSURED
Read declaEtion carefully and mention date (in dd:mm:yy fomat), pla@ (open text) and sign.
U

qffi Policy Schedule - National Parivar Mediclaim 'l

Number:
310600502210003821
aE-rq i-frf, Efr{qlSa/es Channel Code:
9000182927
dttfd.-fdr +gara+/Issuing Office
alq /Name: Mr Jashvant Upadhyay Contact
6 [rqrfrq rts/office code:310600 Number: 8866777598
6r-{qffiq Yil /Office Addressi SURAI s6 rf,TcI drg, / Co Broker Code:
DIVISION I Godavari Bhavan, Above
Handloom House, Chowk Sheri,Nanpura,
Surat, Gujarat, - 395001.
Stare Code; 24, Gujarat
s--sr4{ +{{ ?iil EtI dq{Customer
G STIN : 24AAAC N9967 E1 Zg Care Toll Free Number:
Contact Number: 261 2474495 1800 345 0330
Mobile Number:0
f,*ar
email:customer.support@nic.co.in

mI66' i[T ;IIfr /Customer Name: MR KIRANBHAI PRABHUBHAI rg16+ rffilCustomer lD:
ta /pRtt: BxJPP1571Q
PARMAR 9530034391
cdr/ Address: A- 27, SOHAM APARTMENT 301, MANGAL GROUP qta /Phone:
SOCIETY, City: SURAT, District SURAT, State: GUJARAT, PIN:
395004. {-fa rc-rUait: akashupadhyay.aa@gmail.com
Cell: 9978276578

#6rffi: i2l03/202e d 20:20 t tttoztzozq +1 qt1q {rflf-a-*, 5trrff/Policy Effective from 20:20 hours, on 12103120231o
midniqht ot 1110312024
$afrfr/ Premium ? 7,218.00
CGST
"' "toso.oo

SGST/UTGST { 6s0.00
IGST 0.00 Iqdrq +i.@qI 3itt aEflProposal 880021 031 0445354 Dt. 1 0101 12023
Number and Date
+'s:ffi_fi&w/ { 0.00
Less:GST TDS

5rgT{laft}-rrq Izt{c Ttr( S sltt aBflReceipt

{ 0.00 -qqr 31 06008'1 221 0005730 Dt. 1210312023
fla Number and Date
/Recoverable Stamp Dutv
cffi cffi {t.sqr 3it{ sqlffr 31 0600501910006347 and D1.2810212021
{ 8,518.00 aBf) 31 060050201 0004892 and Dt.0410312022
5O/Total Amount
Previous Policy Number and 31 06005021 1 0004206 and Dt.08/03/2023
Date
Five
€lEI{q SRililGeneral Summary:

Etffiff tprdr;r *alpremium

paying Zone:da l, {t { ffi-{$ Hma 6i-tr{, {iXEr 5+rra/Zone l,Greater Mumbai Metropolitan area, entire
state of

W sn-+fsr #! frqr urflBasic Cover Sum lnsured t100,000.00

Er6q d-rfi d sn-+t"r df fiqr{RlflOutpatient cover Sum NA
lnsured
qlrr{dfid sflq EE{sr sik fq-t-atrfa $EKr4 /lndividual member details and lndividual cover:

Self
2810611984 No
1 KIRANBHAI PRABHUBHAI PARMAR Other M NA No
38Yrs
Emplovees
27t07t1986 Wife No
2 ANITABEN F NA No
36Yrs Housewife
06t1212008 Son No
3 BRIJESH M NA No
14Yrs Students

Printed on 1210312023 by lD: 31060099 Page no: 1

qffi dqqlPolicy Number:
T{T{grq E-frtId /Eusrness Source: 3 1 O 6OO
310600502210003821
aft{q +frd dftf{ur/Sares Channe, Detairs
Br$o.[dr mrgora-+llssurng Office dft{q n-d-d aEFql 561"r Channel Code:
firIqlilq dt /Office Code: 31 0600 9000182927
6.r[qrilq Tdl /Office Address: SURAf dtE/ Name: Mr Jashvant Upadhyay
DIVISION I Godavari Bhavan, Above Contact Number: 886677 7 598
H andloom Hou se, Chowk She i,N anpura,
Surat, Gujarat, - 395001. 6 -sdr{ +'iR etil qt drvCustomer
Slale Codej 24, Gujarat Care Toll Free Number:
C STI N : 24AAACN9967 El Zg
1800 345 0330
Contact Number: 261 2474495
Mobile Number:0 f,trar
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12t01t2012 Son
4 MAAN M NA No No
11Yrs Students

ar6i6fr 6r aFtuilNominee Details :

arq/Name :AN ITABE NYf{dr.r.F' * gfq +idt7nehtionship wlrh proposer:S PO US E

Efr(, sr aEfiqrrpa Details:HERITAGE HEALTH TPA PW LTD - SURAT,601, Meridien Tower, Beside Apple Hospital, Udhna Darwaja,
Ring Road, Surat - 395002 Contact No : 0261 - 4000046 Email :

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r$tQ?tfB artrA f, Td €drifr qaa: Ttnrsftar afrd d snrlfr I /rrv MilvEss wHERE1F, the undersigned being duty authorized
hereunto set hiil her hand at the office address mentioned above, this 12lMatchl2023.This schedule, the attached policy, the c/auseg lhe
endorsements and policy wordings as available in the website httpsl/nationalinsurance.nic,co.in shall be read together as one contract
and any word or expression to which the specific meaning has been attached in any paft of this policy or of the schedule shall bear the same
meaning wherever it may appear. lt is wamnted that lN CASE OF DTSHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT SIATVDS
AUTO MAT I CALLY CANCELLED'AB-INITIO'

tt ftra-a g6lqlt;rs Effi

dfrE/ For and on behatf of National lnsurance
islqt@frBOmbudsman Details: Office of the lnsurance Company Limited
Ombudsman,Jeevan Prakash Building, 6th floor, Tilak Marg, Relief Road,
AHMEDABAD - 380 OO1.
Tel.: 079 - 25501201 102105106 #*
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Date:
Location:

Printed on '1210312023 by lD: 31060099 Page no: 2

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TffrM-c(t /Certificate- N ational P aivar Mediclaim t

cffiI dqqilPolicy Number: +ITgrq qE{td /Eusiness Source: 31 0600
310600502210003821
afrFs i-ra afriqlSales Channel Details
dr0a-1-dr +r{qrfrq/Iss u,r,g Ofi fr ce ERTq d-d-il afrlrsr/ Sa/es Channel Code:
fir_lIqrffi ds /office code: 31 0600 9000182927
41fr/ Name: Mr Jashvant UpadhYaY
6r-rqrdrq cil
/Office Address: SURAI
Contact Number: 886677 7 598
DIVISION lGodavari Bhavan, Above
Handloom House, Chowk Sheri,Nanpura,
Surat, Gujarat, - 395001. 6--s6ff{ +q{ dil qt
d(lCustomer
Srate Codej 24 , Gujarat Care Toll Free Number:
G ST I N : 24AAACN9967 E 1 Zg
1800 345 0330
Contact Number: 261 2474495
Mobile Number:0 fiar
emat

1r*16:6, frI ;IErrcustomer Name: MRKIRANBHAI PRABHUBHAI egrf+ rrf,$lCustomer I D :

ta/pRru: BxJPPt5TlQ
PARMAR 9530034391
tldl/Address: A- 27, SOHAM APARTMENT 301, MANGAL GROUP qtr/Phone:

socl ETY, rrfl/City:SURAT, qfrilDistrictsu RAT,{qq

ggsoo4$t/cell:9978276578 $-fa/e-Hllait: akashupadhyay.aa@gmail.com
/State :G UJARAT, CF/p t N :

ffiZO:ZO a-$, on 12103/2023 t T{firfr 1110312024 +1 e _tr+ tti-difl?r* /Policy Effective from: 20:20 hours, on 12103120231o
ot 11

A Ttlsfur Tl-rilq-qfl /Pr.m ium C.rtif i..t.

:nq{ (+isiltra) ruFFr, 1986 qt tIRr 80 S * r5a *-ctff + Trqtr-4 S dfr'/

(For the purpose of deduction u/s 80 D of lncome Tax (amendment) Act'1986)

T6 y{ffpr6 6;\IR.K|RANBHAI PRABHUBHAT PARMAR A (Tn {8,5'18.00 Eight Thousand Five Hundred Eighteen +d-d rydr'fs
apr srar t
{qqr enstzoz3o31z16624377 Effi 12togt2o23d q;ara 12to3l2o23l 'ntoltzoz+ at 3rfirrs dfr'cfam riqfi stooooso221ooo3821d
firE+q S 3rgrdrd fr erffr dIfir tq $IfiFfi 6r s1zklrd +Er tl
Ttlafrq /Premium <7,218.10
ccST?.650.00. sGSTt.650.0o. tcsT t.o.go. {dr6 1i.qqr d 6<m ryrara afr {lt-.rfr/Payment received vide receipt no.310600812210005730

Effi ldated12lo3l2023.
This is to certifi that MR.KIRANBHAI PRABHUBHAT PARMAR has paid t8,518.00(in words)Eight Thousand Five Hundred Eighteen Only towards
premium for Nitional parivarMediclaimPolicy vide Policy No. 310600502210003821 for the period lrom 1210312023 lo 1110312024 by lnstrument
number EAS12023031 21 6624377 daled 1210312023.
@ ilr+a Ce$ts zitrff EREs/
For National lnsurance ComPanY

EfuEa1vt$qfraTutrft{sv
Duly Constituted AuthoritY

*E : ffi
at req m1e qr T5ffiff qi y{s{rdfr *.{i qrd fifir d'm'frfr crrO * qfrfrrd + Hrs-& d av Saton{t + drfi 6..[}
+ dRr T6 T{ffrq c-fl 61qr *qfi +i ts-*qfr a,rat qrofrt
/Note: This Gertificate must be surrendered to the lnsurance company for issuance of fresh certificale in case of cancellation
of the policy or any alteration in the lnsurance affecting the premium

Printed on '1210312023 by lD: 31060099 Page no: 3

 J

TAX INVOICE

tnvoiCi Seriat tlo: 301 83H2P00003821 lnvoice Date: 1210312023 :

. Deiaits ot
Nalional lnsurance Limited.,
SURAT DIVISION I Godavari Bhavan, Above Handloom House, Chowk Sheri,Nanpura, Surat, Gujarat, - 395OOi
State: 24 , Gujarat
GSTINNo: 24AAACN9967E1Z9

PRABHUBHAI PARMAR
A.27, SOHAM
City: SURAT,
District: SURAT,
State: GUJARAT,
PIN: 395004.

Place Of Supply State Gujarat

State Code : 24
GSTIN No: NA

+{frr E.16

d-dr iFT Sffr(rsA fr rnfl (.flffirerdl(rsdil 3rF6-{/Kerala

3r6fr(r{&/rcST
S-o mtsl aftf*ql qs/ hs fi-rq/ CGST SGST/UTGST
Flood Cess
EFI/Total(
SAC Code Descriptl Discou EtI/Taxable
?)
on of nt value(t)
Service {RIfI {RIf- {Rrfl tRrfhmount(
(flRate Amount( ({/Rate Amount( ({/Rate Amount( {)
tr
Accident
' and health
9971 33
: rnsurance
7,218 0% 7,218 9o/o 650 9To 650 lYo 0
0
services
TOTAL 7 I 7,218 650 650 i 0
EFI 5-daf'{s ffiq (3i61 fr ;totat tnvoice Vatue (ln figures) :
{
mq (rr{dt fi)Totat lnvoice Vatue (tn words) : {rrq/Rupees
E-cI 5-daf'{s
Eight Thousand Five Hundred Elghteen
+dil/onty.
{E-w t 3r?fr-d dl {RtflAmount ofTax Subject to Reverse Charge : No

E.&.O.E
qt ftma {deldt-{s iiqff aBEr ror
and on behalf of National lnsurance Company Limited

,&,w

3fElftd 6{alEEq1E--adil A utho rized S ig n atory

Printed on 1210312023 by lD: 31060099 Page no:4

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Parmar Man Kiranbhai

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l-ather : Parmar Kiiankumdr
Prabhubhai
cr.{ arflu I ooa :1201t2012
!!u / Male

7129 4035 3907

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Address:A_27l301,somappartment,

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hospital,vedroad,Katargam,surarciry,
Surat, Katargam, Gujr"t, SSS00a

7129 4035 3907

E1911
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hclp Ouidai.gov.in
Uw.uldai.gw.in
VR Group of Hospitals Dr.Vimal Dhaduk
DNB, FNB, GASTRO BARIATRIC
501, Param Doctor House, Lal darwaja, Surat, Surat, Gujarat,
lndia SURGEON
7211173111 Reg.No.:G13221

Discharge Summary

PatlentName: MAAN KIRANBHAI PARMAR Sex/AgelWelght: Male / 12 years

Doctor Name: Vimal Dhaduk IPD No: V-231
Admitted Date: 02May 2023 08:00 AM Dlscharged Date: 04 May 2023 11 :06 AM
Ward Namel Semi Special Discharge type : Discharge

Diagnosls :

Prepuceal Laceration due to zip trauma

Clinical Summary :

Patient sustained prepuceal iniury due to zip trauma at today morning with active bleeding. L/E- Active bleeding from
laceration.
After preoperative evaluation patient was taken for surgery. Post operative period was uneventful and patient was discharged
zlafter passing urine comfortably.

lnvestigation :

attached

NAIIE OF SURGERY

t{AilE OF SURGERY:- Circumcision done by Dr. Vimal Dhaduk

SURGICAL NOTES

SURGICAL NOTES:- Circumcision under GA

Circumcision done. Suturing with monocryl 4-0. dressing done.

CONDITION ON DISCHARGE :

stable

Rr
NoAName Dose Detalls Quantlty
1 TAB.Panto 40mg Tablet l -0-0 Before Food - Daily .5 Day(s) 5
2 strip.Dolo 650m9 Tablet 1-0-l After Food - Daity - 5 Day(s) l0
Notes: sos
3 TAB,salvldol sp 111"-o -1112 After Food - Daily
1 TAB.ZIFI cv 200 TABLET 1112 -o- 1112 After Food - DAILY - 5 Day(s) 5
Composition:- CEFIXIME 200 MG + CLAVULANIC ACtO t 25 MG

Operatlon Detalls

Date of Operation:- 03/0512023

Operation Name:- Circumcision done
Surgeon:- dr vimal dhaduk
Anaesthetist:- dr zakir hussain
.
6
Anaasthesla:- GA ,'..)

''\-.-
AUTHORIZED SIGTTATORY

Page I I
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astron
Advanced Laparoscopic, Bariatric - Weight
loss & Gastrointestinal Surgery Centre
6th Floor, Param Doctor House, Lal Danruaja Near
Surat Railway
Station, Surat - 395 003, Mo. 12111 15444

Consultant I ncharge Wt

Name : Mr./Mrs./Miss (
:
Room No &*,i t4
Age / Sex :
Occupation lndoor No :

Full PostalAddress of patient

0
\

Phone No. of patient : Fami Doctor:

Provisional Diagnosis
I

t
Admission
Operation
4l5a r SMfltw
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Discharge tl 6nn
'415t4-
Final Diagnosis

Pr?nthd- Ln"Arrnx d^,Li" frp fyuon x "

Final Status lmproved / Status eou/ DAMA/ Expired

t
PARTICULARS OF ADVANCE DEPOSIT

Date Amount Sing.' Date Amount /:

-l Si

H
 SYMPTOMS OF PRESENT ILLNESS
I

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H/O. PAST ILLNESS I

EXAMINATION ON ADMISSION
B.P. Lying I
Temperature: ,ilr :

-1

B.P. Sitting I
Pulse / min

/ min
Respiration :

,l P.A., c.N.S.) & LocAL EXAMINATIoN

SYSTEMIG EXAMINATIoN (R.S., c.V.S.,

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INVESTIGATIONS

PROVISIONAL DIAGNOSIS

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ADVANtrE
BARIATRItr
GENTER

2* Floor, Ayush Doctor House, Lal Darwaja, Railway Station Road, Surat - 395 003.
ForAppointmenlt 72111 40222lEmergencyContact :7211173444lEmail : gastronhospital@gmail.com
 , :::r: I

Dr. AniI:D.:Shah
M.D. (Peth.) D.C.P.
Regd No.: G 7360

f^trilmtatrt
J.r2fiOml.h.l$lB
Main : 116-120, 1st Floor, National Plaza, 0pp. Ayurvedic College, Near Railway Station, Surat. Ph. No. : (L) 2418165, Mo. : 90331 87226
Collection Gentre: lst Floor, Nr. Hasti Mart, 0pp. G.M. Computer, Beside Navrang Juice, Parvat Patia Rd., Parvat Patia, Surat. Mo. : 84908 14455

TEST REPORT

Patient ID : 15044
Patient tame : MAAN Regisrered on t o2-May-2o23 08:45 AM
Age/Gender : 12 Yrs Male Sample Collected On : 92-g6r-2023 08;53 AM
Ref. By : VIMAL DHADUK(DNB.SURGERY,FNB) sample Reported on :02-May-2023 09:47AM
Client : Dired

Test Name Observed Values Unit Bio Ref. lnterval DIFF

HEMOGRAM EXAMINATION REPORT
?:
(By BC-760(B| Hematology Analyzer,MltrlDRAYl

lTotalWB.C Count wo /c.mm 400&10000

#, *r
R.B.C. Count 4.96 m/c.mm 4.5-5.5
Hemoglobin g/dl DlFFGnaph
12.2 13.S18.0
Dlatalal Oarnl 466000 150000400000
\A/BC
Packed Cell Volume (HCT) 37.2 o/o
40-50
Mean CeiiVolume(MCV) 75.0 fL 75-95
Mean Cell Hemoglobin( MCH) 24.6 pg 27-32
Mean Cell Hb Conc(MCHC) 32.9 g/dl 31-36
RDW.sD 423 o/o
35-56 o

DIFFERENIIALWBC COUNT V\IBCGraph

Band iorm Celis 00 nlo

0-5
Neutrophils 51 o/o
4A-75
Lymphocytes 38 Vo 20-50
Monoc$es 08 o/o
2-12
Eosinophils 03 o/o
16
Elaeanhile
Huvvr.n'e
n
VU
o/^ a-2 o
HYPochromia MlLD RBCGraph
^' Platelete appear on the snEar INCREASED
MP by Thick & Thin Smear NOT DETECTED

'PLTGraph

Teet Name Observed Values Unit Bio Ref-

SERUM CREANNNE ESTIMATION

CREATiNINE 0.55 mg/dl 0.5-1.5 /I :

Enzymatic Method

Page 1 of2

?t.rq ert"u, rJFsq',r lCleer ria)Rrdcr.l dor'llaJl lClen.r 1r)o)cr)g1*e aetuqrlQrcr dq'llaCl tlr. Anil D
cqptl?tta qrd eilcrryqc-rqllcr - dlrrruqltqrrid MD (Path) D.C.P
UqleNq.{. : troC Put3/,tingExc,//erl[!
 CONDITIONS OF REPORTING

* Report results are forthe information of the referring doctor only.

* Tnis report is not valid for medico-legal purposes.

* lndividual laboratory investigations are never conclusive but should be use along with other relevant clinical examinations
to achieve final diagnosis. The results of a Laboratory investigations are dependent on the quality of the sample as well
as the assay procedures used.

* Partial reproduction of this report is not permitted.

* Rny disclosure, copying, distribution or taking action based on the contents of this report by any person other then referring
doctor is strictly prohibited and unlawful.

* The results relate only to the sample tested. The same sample will be available with us for 24 hrs (depending on the
stability of the analyte) if required for retesting for second opinion. lf retesting is done from separate sample then Heer
Clinical Lab. may not shoulder responsibility for discrepant result due to technical reasons.

+ HCL, proprietor and employees / representatives of HCL are not liable or responsible for any loss or damage that may be
incurred by any person as a result of presuming the meanings or contents of the report.

* Result of the tests may vary from laboratory and also in some parameters from time to time forthe same patient.

* ln case of collected sample(s) which are referred to HCL from a referral laboratory it is presumed that patient demographics
are verified and confirmed at the point of generation of the said specimen.

* Tests are performed as per the test schedule given in the test listing. ln unforeseen circumstances ( non-availability ofv
kits, instrument breakdown and natural calamities) tests may not be reported as per schedule. HCL will make all the efforts
to minimize the delayof reporting.

* lf the collection date was not stated in the Test requisition form, the date of receipt of specimen will print by default as the
date of collection.

* Atest requested might yield "lNCOf\4PLETE RESULT" forvarious technical reasons.

o Quantity Not Sufficient

. Qualityof specimen received is unacceptable ( hemolysed/lipemic)

. ln above instances a fresh specimen must be sentfor purpose of reporting the same parameter.
* Subject to SURAT Jurisdiction.

* Anyqueryfromthereferringdoctorwithreferencetothisreportshouldbedirectedtothepathologiston
Tel. No.0261-2418165

:'..,,
 @
Dr. AniI D. Shah
M.D. @eth.)D.C.P.
RcgdNo.: G73fi
rld0t{rr!
' Jr.2!13,&l.J}t$2003
Main : 116-120, lst Floor, National Plaza, 0pp. Ayurvedic College, Near Railway Station, Surat. Ph. No. : (L) 2418165, Mo. : 90331 87226
Gollection Gentre: lst Floor, Nr. Hasti Mart, 0pp. G.M. Computer, Beside Navrang Juice, Parvat Patia Rd., Parvat Patia, Surat. Mo. : 84908 14455

TEST REPORT

Patient ID : 1502t4
Patient Name : MAAN Reglstered On . 02-May-2023 08:45 AM
Age/Gender : 12 Yrs Male sample collected on : g2-gqr-2023 08:53 AM
R.ef. By : VIMAL DHADUK(DNBSURGERY,FNB) sample Reported on : o2-May-2023 09:47AM
Client : Direc{

Tcst Neme Observed Values Unit Blo Ref.lnterual

RANDOi' BLOOD SUGAR

RBS 1U.21 mg/dL 80-140
GODPOD Method
A. Urine Sugar - R Absent
UrineAcetone - R Absent
Test Name Obserued llalues Unit Bio Ref. lnterval

HUMAN IMMUNODEFIGIENCY VIRUS I & II

Hlvl&ll Nonreactive Nonreactive

Rapid lmmunochromatography

Lrlli,lLl

Page 2 oI 2

dq)laJl Dr' Anil D 'r

?tcrq erur, ellBqq lClse ?ier)lirder4 dor)laJl lClrllq (ie)c{)vl dcr antyqrl0rcr
aqpr ld*ru qrl e'lrrruqcqrllcr - cjlrtruoilB"{t{0 MD (Path) D.C.P
Yqlenlq ol. : Uo?
 CONDITIONS OF REPORTING

* Report results are for the information of the referring doctor only.

* tnis report is not valid for medico-legal purposes.

* lndividual laboratory investigations are never conclusive but should be use along with other relevant clinical examinations
to achieve final diagnosis. The results of a Laboratory investigations are dependent on the quality of the sample as well
as the assay procedures used.

t Partial reproduction of this report is not permitted.

* nny disclosure, copying, distribution or taking action based on the contents of this report by any person other then referring
doctor is strictly prohibited and unlaMul.

* The results relate only to the sample tested. The same sample will be available with us for 24 hrs (depending on the
stability of the analyte) if required for retesting for second opinion. lf retesting is done from separate sample then Heer
Clinical Lab. may not shoulder responsibility for discrepant result due to technical reasons.

+ HCL, proprietor and employees I representatives of HCL are not liable or responsible for any loss or damage that may be
incurred by any person as a result of presuming the meanings or contents of the report.

* Resultofthetestsmayvaryfromlaboratoryandalsoinsomeparametersfromtimetotimeforthesamepatient.

* ln case of collected sample(s) which are referred to HCL from a referral laboratory it is presumed that patient demographics
are verified and confirmed at the point of generation of the said specimen.

* Tests are performed as per the test schedule given in the test listing. ln unforeseen circumstances ( non-availability oY
kits, instrument breakdown and natural calamities) tests may not be reported as per schedule. HCL will make all the eftorts
to minimize the delay of reporting.

* lf the collection date was not stated in the Test requisition form, the date of receipt of specimen will print by default as the
date of collection.

* Atest requested might yield "INCOMPLETE RESULT" forvarious technical reasons.

r Quantity Not Sufficient

r Qualityof specimen received is unacceptable ( hemolysed/lipemic)

r ln above instances a fresh specimen must be sentfor purpose of reporting the same parameter.

* Subjectto SURATJurisdiction.

* Anyqueryfromthereferringdoctorwithreferencetothisreportshouldbedirectedtothepathologiston
Tel. No. 0261-2418165 &f
 Gastrorf
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202,2'o Floor, Ayush Doctor House, Lal Darwaja, Railway Station Road, Surat - 395 003.
For Appointmenl'. 7211140222 | Emergency Contact :72 111 73 444 | Email : gastronhospital@gmail.com
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: li tll /OiU2 | En rg.nst corLdt721ll7l4/4 | Ensil : ga!tsoohoErtul@mail.con
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: 7!lll 404!2 | Emergpncy Conlad : rll ll'l 7:l ai+l I EImll : g.ttsonhoopital@gBEil.com
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: Zllt /oza I Em8rgsrcy Cor .ct : z lll 73 a,at I Enail : gatbonhorpittl@n ll.com
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hrABohtr : llltt a0Z2 | Enorgency Contact: 72lll 73 ullEmail : g!.tonhorptbl@m.il.com
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 :

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ILh tt6-t20, llt Floor, Nldorlat PLaa, OB.
: N,
ayurvdic Golhga, I'ler h.irway B
Gd.ldolr crtt: tn Fbo., r. ]bri
M&t orp. OM. CorrTrabr, I.TTII .rtang
srauorL Slrst. Ft. No. (Ll 24
Juicq Pivat zEt Rd., lbrird Pni.,
9t65. m s3t rrzz6
&rat frl : C4S0 tart55 N
K
I INVESNGAIION BILL
No. ! ,50it4
; iIAAT{ Bill No I 26622
A9e/Gender ! 12 Yrs PID . ttT_ 22,640
Moblle
/ Male Employee ID VTNOD PARMARI
Client ! Direct Regn. Date : 02-May-2023 08:45
AM
Ref, By : VIMAL DHADUK(DNB.SURGERY,FNB)
Sr.
I IIEMOGRAM EXAMI NATION
REK}RT (cBc) Amt Disc
2 HUMAN IM MUNODEFICIEN CY 280.00
VIRUS I & u (Hrv(P*PlD) 0.00
3 RAI{DOM Bi-ooD SUGAR (RBs) 400.00 0.00
4 SERUM CREATININE ESTIMATION 50.00
(CREATININE) 0.00
190.00 0,00
Amount fn IEI Gaos3 airrrT

lriqQ Hundred Twenty And Sub Totrt Amount

Zero patse Only.

Amount

fhb ir.n .lGcttrr !.Gr.t d bllt hcnc. d6. rot Gqul...lgn.tllrr

G.lly

Ilote! you arc rcqu6tcd to y€rr:fy thG test

details with Slgnatulr
 .l

,tg
tsrr?F#d r Cl=H3g
:rlrrf'tft
AA OlslAuSdns L
 CrI latto PTEASE CONSULT YOUR DOCIOR
2ND FIOOR, AYUSH DOCIOR HOUSETAL DARTIAN BEFORE USING THE TGDICINES
Elill No. : ?34
:N-217(N,21217010,, GSNN24AEYPD6ffBE1ZF
Bill Date: Omsfillt23 ilot b No.

MAAN PARMAR Area: 1D

Docbr: DR VIIT,IALDMDUK
ag. }i!tn!l il1l]l'.Il Amoun[
I VEIN FION 22
Dircounf T[Ar mFtlt
t 7:{f$ 09-26 258.m mrn ,2.00 0.m 27.61
1 FTAi/IIGRIP FX 025A021 12-21 80.m t2.m 0.m mrl
1 AIPL VENT INFUSION SET ORA 0RAi575 11-25 255.m 255.m 12.00 0.00 27.n
1 Ei,ESEr 2lr- INJECTION NS2r61sSR 11-zJ 1X.12 13.12 12.6 0.m 1.40
1 AKUME INJ D't052115.1 tGa 250.m 250.00 12.00 0.m 26.78
1 FEBRINIL II{J
FLM101 12-?3 20.35 20.35 12.01) 0.m 2.18
il RL 500tf ctxx_ 1u5708 '11-25 56.14 1m32 12.00 0.m 18.14
4 NS 500 i,l, ['rAffiN 10-28 56.34 zE.fi 12.fi 0.m 21.1t
2 NEOROF Mt[ INJ aKm &21 ,76.m 362.m 12.m 0.00 37.72
1 PYROLATE INGCIION IXIITEII]i 1G25 11.38 1a.38 12.@ 0.m 1.54
1 IEZOI.AM INJ NEON 11-n F.T':il Ff{il 12.N 0.00 6.95
2 MONOCRYI3{ lilv 1326 JNJ 11-21 ffif':il Elif':il 't2.00 0.00 d2.14
2 SURGICAL GLOVES 7.5 llf'f,|F.'Ii'l &24 101.m mxr|li] 12.00 0.m n.28
MICROPTIC 7
2t06mm6 06-24 104.00 208.m r2.m 0.00 22.8
2 PI.A}N SHEEI 1M?10 MAY1MsD 02-25 $7.m 911.00 't2.00 0.m 97.9)
2 HIV KTI PREMIUM Ps210208 01.26 1170.m 0.00 zfi.72
1 IRUSANIZ SANTTEER EE 032it 6m.m 0.m 70.72

.Tl Toarl b.!: 26

m 3
Round ofi: .0.38

Nino lhol.lsfld Orle HundEd Turnty Fcur n{66 Soakr b, t{o&{t

 !IIr, Crt Ieno PT€ASE CONSULT YOUR DOCIOR

2ND FIOOR, AYUSH DOCTOR HOUSEI.AI, DARTTAA EEFORE USING THE IEDICINES
:
Bill No. 234
' 217cfp 21-217010,, GSTlN2lAEypD6ffm12F
EllDah: (1211152023 Mobih No.

MMN PARMAR Area: m

Docbr: DR VIII,IAIDHADUK
.IEIII
Pmfict Ill m;mt Ee. Armm FfiI rl?rI7l TuAmt Amount
1 ERBE NESSY OICGA PLA1E 18061t-2100 315.00 345.00 r2.m 0.00 38.96
6 GAUZE swAE 10cM x 10cM (B) 0114T21 0&24 100.m 6q).m 12.00 0.00 61.28
8 GAUZE SWAB SClt X 5CM (S)
029Ar2,| w24 80.00 610.00 12fi 0.m mm
2 JELONEI IO DRESSINGS IOC X GS10'l 11.24 44.50 89.00 12.@ 0.00 9.t{
10cM

7 ONE PRICK SYR IOIf, 1G25 55.00 385.m 12.N 0.m 11.21
6 SYRINGE sii- oNE PRIC|( I 11-23 30.m 180.m 't2.00 0.m 19.n
2 ONE PRICK SYR 2TI-
0!25 6.N 50.m 12.m 0.m 5.36
WOKAOINE SOLUTON 47t]f042 1Ez3 90.90 90.90 12.00 0.m s.74
ADVENT 1.2 INJ CA/A@ 02-21 131.S9 13't.S0 12.fi 0.00 14.14

lr

n Toarl lt!m: 28 |'fitr.r1 mil 0

Round oft: 4.38
NinoThqEand Ono Hundr6d Turnly Four rupG SdUE by
Ch€mbt Sign
N.osott S.riEd026'l-2568182) E. & O.E. Amt 912d00
 Dr. VimalDhaduk
VR Group of Hospitals DNB, FNB, GASTRO
601, Param Doctor House, Lat darwaja, Surat, Surat, Gujarat, lndia BARIATRIC SURGEON
PIN: 395003 | C0NTACT NO: 7217173444 Reg. No. :G-43221

::

Paiient Name: MAAN KIRANBHAI PARMAR Bill Date: a2MaY 2023

: Age: Male/l2 Years BillNumber: VR-9585

Particulars Unit Rate Amount

l;i.st Appointment 1 600.00 600.00

Amount 600.00
Total Payable Amount 600.00
Paid Amount 600.00

Total Payable A SIX HUNDRED Total in Advance: 0.00

ONLY

Paynrent Method: CASH For, Vr ls

 aIIII[illn I-.llr'l-t,ii,:'! PT.EASE CONSULT YOUR DOCTOR
BEFORE USING THE ITf,DICINES
2M,2ND FIOOR, AYUSH DOCTOR HOUSEI.AL DAR AIIT : 2{6
Bill No.
D.L.N0.;2O217009,2'1.217010,, cSTtN:24AEypD6dtrEtZF
PAN:AEYPD6633E EllDab: 0{J05I2023 Mobile No.

Palient fuIMN PARI\,AR Area: ln

ibr: DRVIT,IAI.DMDUK
Ay. Ptoduct Eqr
L!.I'I AltEtnf rNTI DF...rjtill TuAn[ Amou
5 AI(UMB INJ D1052115' 1GA 250.00 't250.00 12.N 0.00 133.92
5 2iI.
EI,ISEI INJ rT[.m 12-24 11.53 n6 't2.00 0.00 7.78
4 FEBRINIL INJ RMI12 03-24 20.3ti 81..l) 12.@ 0.m 8.72
5 ADVENT I .2 INJ c2vA62 v2-24 131.99 659.95 12.@ 0.00 70.70
4 NS 500 [f, I.IAf'ltJIl rG26 56.34 225.36 12.fi 0.m 21.11
3 RL sOOM- 1u5708 11-?5 56.1,1 169.32 12.N 0.00 18.'14
31 ONE PRICK SYR lOIf, 1G25 55.m 495.00 12.N 0.00 53.04
5 SYRINGE 5T{- ONE PRICI( tt6a017 11-23 30.m 150.m 12.fi 0.m 't6.08
5 ONE PRICK SYR 2[I- 3SB20t0 't25.00
0G25 25.m 12.M 0.m 13.10
2 SURGICAL GLOVES 7.5 ZIE{'F^[Ii5 &21 1M.m zrriit 12f0 0.00 D..2A
2 GAUZE SWAB 10CM X tocM (B)
w21 1m.00 2m.00 12.N 0.m 21.A
2 JETONEI 10 DRESSII{GS IOCM X GSl0r 11-21 44.50 83.01) 12.fi 0.m 9.5d
't0cM

t0 AH 2M TAB' FDC 01anE6 0&a 107.m 107.60 t2.00 0.m 11.52

t0 PAN 40 TA8 2't14298 @24 119.00 99.33 12.N 000 10.d1
ACEDAY-SP CACH 08-24 103.m 't03.00 12.m 0.m 11.01
t0 D0l_0 650 TAB &21 n.71 m.& 12N 0.00 2.m

m Tohl tbn: ,6 ff'tr il m{r'l 0

Roundofi: 4.06
olcnin{iigr
FourItous d Fity Six .gib3b, x.o S.alSqtic&1026f2{681E2} E. & O.E.
EilEII
 P!Tr55 PTEASE coNsutT YouR oocroR
2NO FTOOR, AYUSH DOCIOR HOUSEI.AL EEFORE USING THE }EDICINES
DAR AA BillNo. : 270
GSTIN2IAEYPD6dBE'IZF
BillDab: 0t/105/2023 It obile No.

MAAN PARMA,R
Area: 1t1
Docbc DRVIMALDTIADUK
Ay. Prcduct :11'!trI'.|.l Ee. ,l r.ri,il rdi l iM!.!71 t-trr:li7r A|tnfl
JELONEI,IO DRESSTNGS toct x GSr0l 11-21 11.tu 44.fi
'tocM 12.N 0.m 4.76

2 GAUE SWAB 10CM X 10C (B) 0&2{ 1m.m 2m.m 12.N 0.00 21.4
SURGIC,AL GLOVES 7.5
zmiEiltiF 0&2il 104.m 208.00 r2.00 0.m n.28
zH 2m TA8- 012Affi6 0&23 107.61, 53.80 12.N 0.00 5.76
PAN 40 TAB
EIIT]B] fi-n 138.@ 46.00 ,2.00 0.m 1.92
10 CHYi'ORAL FORIE TA8
11-21 alrfil 192.95 't2fi 0.m 20.68

r5 TotrN iml: 0
r'n f'l
Romd olt: -02.
S€v Chqnkf Sign
Hundrcd FffV Fflr ll,oes r.lri! b, EFTI E. &O.E.
 'a

VR Group of Hospitals Dr, VimalDhaduk

DNB, FNB, GASTRO
601, Param Doctor House, Lal darwaja, Surat, Surat, Guiarat, lndia BARIATRIC SURGEON
pll+: SSSOO3 I CONTACT NO: 721 117g444 Reg. No. :G-43221

Patient Name: M,qAN KIRANBHAIPARMAR Bill Date: 08 May 2023

Sex/Age:. Maie/12 Years BillNumber: VR-9616
Particulars
Unit Rate Amount
Follow-up Appointment
1 400.00 400.00
Dressing Charges
1 700.00 700.00
1100.00
Total Payable Amount 1 i 00.00
F*A[d An*6unt 1100.00

Total Payable Amount: 0NE THOUSAND ONE HUNDRED

ONLY

tment Method: CASH

For,

AUTHORI RY
 VR Group of Hospitals
Dr. VimalDhaduk
601, Param Doctor House,
Lat darwaja, Surat, Surat, DNB, FNB, GASTRO
Gujarat, lndia
PIN: 395003 I coNTAcT BARIATRIC SURGEON
No: 72111iekq
Reg. No. :G-43221

Patient Nam e: M AA N KIRA

N E-l HAI PARMAR
Sex/Age: Bill Date: 06 May 2O2S
Male/1 2 Years
BillNumber: VR-9607
Particulars
Appointm ent Unit Rate Amount
Dressing Charg es 1 400.00 400.00
1 700.00 700.00
Billed Amount
1 100.00
Total Payable Amount
1100.00
Paid Amount
i 100.00

Amount: oNE THousAND

IoSr.r.ble oNE HuNDRED
Total

Payment Method: CASH

For, q/oup of ls
. 'i,
11 *
AUTHORIZED SIGNATORY
 3':_!trr,l5 PIEASE CONSUTT YOUR DOCTOR
2ND FLOOR, AYUSH DOCTOR HOUSEI.AL DARIUAIA BEFoRE USING THE lrGDtCtNEs
Ell No. : 256
DI.No. :2u2r7009,2i -2i2010,, GSTttt24{Eypoffi t3EtZF
PANNEYPD6633E BillDab; ll6llM02t lilotile ilo.
Pjqert MMN PARMAR Area:
t .or: DR VIIITAIDHADU(
111

otv.
tr'! EIp. Anomfi TuArnL
2 SURGICAL GLOVES 7.5 Amou
210m50405 w24 1M.N 208.m 12.fi 0.00 n.28
GAUZE swAE 10CM X 10CM (B)
2
i]II['II &21 100.m {tftn i2.m 0.m 21.A
JELONEI 10 DRESS|T{GS 10cu x GSl0r 11-21
',0cM 44.51) 44.50 12.N lfin 4.76

R ToaJilol: 3
rgF.i1 [ti] 0
Round ofi: -017
For Hun*€d Im n{ors Chmi{ tiisl
Em! b, IEFq:I E. &O.E
VR Group of Hospitals Dr. VimalDhaduk
DNB, FNB, GASTRO
601, Param Doctor House, Lal darwaja, Surat, Surat, Gujarat, lndia BARIATR!C SURGEON
7?1Xt3444 Reg. No. :G-43221

pt
Ru.ceipt No.: 11 1
Date: 04 May 2023

R.:c€ived with thanks from Mr./Mrs. MAAN KIRANBHAI PARMAR the amount of rupees
25175.00 ( Twenty Five
Tnousand one Hundred Seventy Five only ) towards full payment of Bill no. lv-l11 Dated on
0a May zozs

Payment Method: Cash For, VR Group of Hospitals

Creques are subject to realization AUTHOR SIGN.ATORY

VR Group of Hospitals Dr. Vimal Dhaduk
601, Param Doctor House, Lal darraja, Sutat, DNB, FNB, GASTRO
Surat, Gujarat, lndia BARIATRIC SURGEON
pl,^agsoo3 t CoNTACT NO:
7211173141 Reg. No, :G-41221

Patient Name: MAANKTRANBHATPARMAR

Bill Date: 04 May 2023
Sex/Age: Malel12 Years Bill Number: tV-111
WardDetail: Semispecial Admitted Date: 02 May 2023 08:00 AM
IPD No: V-231
Discharge Date: 04 May 2O2g 11:06 AM
Particulars
Unit Rate Amount
Registration Charges
1 200.00 200.00
Room ch rges + N ursing ch arges
3 1500.00 4500.00
Dr Visit First
1 1250.00 1250.00
Dr Visit Routine
4 800.00 3200.00
Ot charges
1 3664.00 3664.00
Pr^:dure Ch arges
1 9161.00 9161.00
anesthesia cha rges
1 2500.00 2500.00
Dressing Cha rges
1 700.00 700.00
Billed Amount 25175.00
Total Payable Amount 25175.00
Paid Amount 25175.00
 ,J,{$*,

ClshLtm PTfASE CONSULT YOUR DOCTOR

2NO FTOOR, AYUSH OOCTOR HOUSELAI. DARWAA BEFORE USING THE iEDICINES
Bill l,lo. : 3ll8
DLNOr:2G2170092f2170i0,, GSTTN:24{Fypffi }3EiZF
PANtrEYPD6d}3E BillDab: lEl05l202:l ilobile No.

MMN PARMAR Area:

owbr: DR VIMA|_DHADUK
111

otv. Pmdud mt r-ti]flll Elp. Amunt DLcounl

2 SURGICAL GLOVES 7.5
TuAn[ Amou
&24 101.00 m8.m 12.N 0.m D.28
2 GAUE SWAB tocM x if'En (8) &21 t00.m m0.m 12.00 0.00 21.n
JELONET 10 DRESSTNGS t0cMx GSt0r 11-24 44.50 41.tu 12.@
,ocM 0.m 1.76

Ha

4
>
3 Tohllbm: 3
rnil :rl

Round Ofi: 417 ,ti

tur tltrdEd s:Fu v i5
ffiSbn
E &OE
VR Group of Hospitals Dr. Vimal Dhaduk
601, Param Doctor House, Laldarwaja, Surat, Surat, DNB, FNB, GASTRO
Gujarat, tndia BARIATRIC SURGEON
PIN: 395003 I CONTACT NO: 7211173444 Reg. No. :G-43221

Patient Name: MAAN KtRANBHAt PARMAR

Bill Date: 16 May 2023
Sex/Age: Male/l2 years BillNumber: VR-9636
Particulars
Rate Amount
Follow-up Appointment
1 400.00 400.00
Dressing Charges
1 700.00 700.00
Billed Amount 1,100:00 ,

Total Payable Amount 1 100.00

Paid Amount 1 100,,00

Tota\Pavable Amounr: oNE THousAND oNE HUNDRED

1..
0.00

Payment Method: CASH

Fo

AUTHORIZED SIGNATORY
 2ND FTOOR, AYUSH OOCTOR HOUSELAL
CdI{m PITASE CONSUTT YOUR DOCTOR
MRIYAIA BEFORE USING THE tTEDICINES
tlill No. : 2E9
D.L.NO.:2O217009.21.2i7010
PANNEYPD6633E EllDab: lll05t2023 ilobile llo.
Patient MAAN PAR]IIAR
Area:
Doc,tor DR VIM/(D||I{DUK fi
otv. Pndu.i
EEI'.t:l Ep. fulormt GSIX
2 SURGICAL GLOI/ES 7.5 TuAnt Anounl
2106050,t05 &21 104.m 208.00 12.fi
2 GAUZE swAg tocM x 'tocM (8) 0.00 2.8
014AT21 &24 100.00 Tdif'n 12.@
1 SURGICAL BUDE 11 0.m 21.A
GENA D1 07-27 8.00 8.00 12.@ 0.00 0.86
JETONEI lO DRESSINGS 10C X GSt0'r 11-21
10cM '1,1.50 4450 12.m 0.00 4.76

ti Tohl bm: 4
mil til
1l
Rourd 0f: -O.it
Four Hud6d Si*ynpc
t
Solhr [:tFf;l
Ch€mi{ Sign
E, &O.E,
VR Group of Hospitals Dr. Vimal Dhaduk
DNB, FNB, GASTRO
601, Param Doctor House, Lal darwaja, Surat, Surat, Gujarat, tndia BARIATRIC SURGEON
PiN: 395003 I CONTACT N0: 721 1179444 Reg. No. :G-43221

Patient Name: MAAN KIRANBHAIPARMAR BillDate: 11May2023

Se,1($9e: Mate/l2 Years BillNumber: VR-9631
Par rlculars Unit Rate Amount
i'ollow-up Appointnrent 1 400.00 400.00
Dressing Charges 700.00
1 700.00
Billed.Amount 1100.00
Total Payable Amount 1 100.00
"Faitl Amount 1100.00

Total Payable Amount: 0NE THOUSAND ONE HUNDRED Tota! in Advance: 0.00
ONLY

Payment Method: C.ASH For, Vr group of hospitals

t AUTHORIZED SIGNATORY