(Form P-1) Employees State Insurance Corporation

Bapunagar, GJ (ESICModel Hosp.)

Referral Letter
DO NOT MUTILATE THE QR CODE

Referral No :Gujar2023045897 Insurance No/Staff/ Pensioner Card :3713122577

Name of the Patient :Mr. PARMAR BHARATBHAI Age/Gender : 33 Years /Male UHID : HBAP.0000095296
UAN of IP :101509104812
Affix 3.5x4.5
Address/Contact No Photograph of
Identification marks (ifany) Patient
IP/Beneficiry/Staff
Relationship with IP/Staff
:IP
:Self
Entitled for Specialty Rx :YES
Entitled Super Specialty Rx :YES
Diagnosis : ICD - Secondary thrombocytopenia - D69.5 Remarks :
CGHS (Name andCode)* :NCHI - Non CGHS Health Intervention -Unlisted Procedures/Tests- No Of
Sessions Allowed - 1 - Validity Upto - 31-Oct-2023
Remarks Additional Clinical Information/ Procedure/ Investigation
Reasons / Purpose for Referral Investigations/Rx/ Procedure: inj.Romiplastim(500mcg) With day cbre adrmisinSUNITA BHALAKI-

Name of the empanelled hospital whereto refer Hospital EMPANELED HOSPITAL GUJARAT SI Gì i . / MEDICAL OPD
Department Haematology Clinic
aTIE, TEHCTATE /Bapunagar, Ainmedabad.
rt TET:Reqistraion No.G-19di6
Date & Time of Referral : 21-Oct-2023 10:02:31 AM Name and Designation of the Referring Doctor
Dr. Rohit Vala - IMO

Or,Agreeing to / contradicting the above, Ivoluntarily choose Hospital for treatment of self or
for my (relationship),
Date and Time:
Signature/Thumb Impression of IP/Beneficiary/Staff
Referred to Department of Hospital/Diagnostic
Centre for ( Reason/purpose for referral).

(VERIFIED & RECOMMENDED BY) (AUTHORISED SIGNATORY WITH STAMP)

(Signature, Name &Designation) (Signature, Name &Desighation)
Date & Time:
Date & Time:

DR. HCAAVERI
IC 1.M.0. CLIL, D4, E.S1.S.
N.B.
CHANGODAR, ABAD,
The entitlement eligibility of the patient should also be verified
ROverned by the rules and administrative instructions issued through IP Portal at www.esic.in. Referral shall be
from time to time.Referred Hospital is instructed to
only those procedure/treatment for which the patient has been referred to. In case perform
treatment Tinvestigation is essentially required to be carried out, permission for any additional procedure
the approving authority of the referring hospital. The the same is mandatorily required from
validity of this referral is upto 7 days from the date of issuance or
as per the contract whichever is later and is subject to fulfilment of other
Contract/agreement. terms and conditions as defined in the

Printed By :rohivala
21-10-2023