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    © All Rights Reserved
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    12 views9 pages

    Final

    Uploaded by

    hyperpintro
    These is project file

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 9
    SS) FHPU REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART —C (TO BE FILLED IN BLOCK LETTERS) DETAILS OF THE THIRD PARTY ADMINISTRATOR/INSURER/HOSPITAL a. Name of TPAfnsurance Company: Family Heath flare Trsumunce Tes Limi », Toll free phone number: goo 425-4033 er _tgoo-tea—o33 “\eoo-425-4033 ew __teeo-ten—neog3 «Toll free fax: ae B\ to -23FNHOO 4. Name of Hospital: PD HINDUJA NATIONAL HOSPITAL & M.R.C, MUMDAL hVnaatess VEER SAVARKAR MARG, MAHIM, MUMBAI-400016 ii, Rohini 1D: Ped eee ii, Email ID: (i ‘TO BE FILLED BY INSURED/PATIENT ‘A. Name of the Patient: Gemnath aryonteo Beye Gender Eq Male] Female [] Third Gender CARs [OB] Years CIE] Moms . Date of Binh estes liage E, Contact Number: siéyesaaay F. Contact number of attending Relative: G. Insured Card 1D number: qeouSootlrd 12.418335 Hi Policy numberName of Copore: _ 56.0000 (4H 12004 EN 1. Employee ID: usa2\ 4, Currently do you have any other medclaim (heath insurance? Dl vs [] v ‘CompanyName: Mylan Latrotomet, Sinner, mechile i, Give Details: al g Fob, Meteqeon MID Sinner NULhIE Mmahunatdbe Do you haves fait Physician? Ove Fm LL. Name of the Family Physician: ss ———| M, Contact number, if any: ER Galen a IN. Current Address of sured Patient: sobbed Pawel! , pest — Kanan , Ter Sangamne 914 ©. Occupation of Insured Patient: Rin Hat eer gob VPage aus oS (PLEASE comuere pectaaTionorTusrow) — = I> REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY A. Name of the treating Doctor: DR_ SANJAY AGARWALA B. Contact number: .ORTHO, MS (ORTH), (BOM), HH. ORTH (ENG) ne Uae age | . Nature of Iliness/Disease wi presenting complaint adap BIL hip AUN” .. Hind Hospital & Breach Candy Hospial Mumbal EG. NO. MMC 42011 Ble nip pain frercterness fol Ahcod fon get ei Puss BP CNS PA =ORS”~—CVS D, Relevant Critical Findings: Born painhit. unk fevtricte A. E, Duration ofthe present ailment: : i Date of First consultation Al6i2oV& ii, Past history of present ailment, ifany: F. Provisional diagnosis Gladeval hip Wwaxoley pees i ICD 10 code: G. Proposed line of treatment: ‘Medical Management = (+) ii. Surgical Management (&~) i ii. Intensive care C ) | iv. Investigation ¢ DI vy. Non allopathic treatment ( ) . investigation andlor Medical M TROBE eC eg Are a A ESTE Tu fovet 1 surgical name of ergy Riyhrs Toler HIP Beplacem

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