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BAJ AJ I Alllanz(ffi)
Bajaj AUianz General Insurance

Co ; Ltcf ,

ANNEXUREB
Pre-Authorization for Cashless Facility

Hospital Code: BAGIC H : 363

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'

BAJAJ ALUANZ GENERAL INSURANCE CO. LID;

Ground Floor Ashoka Plaza
32/2 Nagar Road, Wadgaon Sheri
Pune - 411 014
Phone: 1800 1025858 (ToU Free) / (020) - 26500203/232/242/30512229/232 (STD). Fa x: (020)-30512224/226/227
Email: health@bajajallianz;co.in
.
Beneficiary Name:

L. D. Card No, __________ ,-- __

Expected Date of Adm ission :

Age/Sex: _ -'- __
Name of Treating Doctor: ,

days

.Registration No .: _______________ _,_-----"-PD

Name
of. Hospital:
City _Mumbai State_Maharashtra

.~

Policy No,

__________ E xpected L ength of Sta y:

HINDUJA

Details of Signs and Symptoms related to the present ailmenn ,

Duration of AiIrr ient:

NATIONAL

HOSP ITAL

MEDICAL

&

RESEARC
H

CENTRE

__________________ ~ _____________ _'_ ________ .:... ______ __' ________ _

Provisional Diagnosis: __ _'_ _ __' __ __'~_-'-,.:- __________ "__.:... _________________ _

PLEASE STATE IF THERE IS PAST HISTORY OF THE FOLLOWING AND DURATION;

Disease / Ailment
I lypcrtcnsion/' cardiovascular diseases

Diabetes
Asthma
. "fir

SUfl..'I.:rv/hospitali%ation

I'm- other disease I disnbilirv

Obstetric 1 Iistory / Past Ob / (;y Sur~<:r)'

. Past History
(Yes /No
(Yes /No
(Yes INo
(Yes /No
(Yes /No

Duration/ other deuils

Status: G .....~ .~ P. ....... A ..... .1 ..... Lj\[j>; ................... , .................

Wa:''<thc illness or injury due to the use of

a1c()I\(~1O rintoxicatinu Jrug,;?
Intentional self injuf\ '

(Yes / No)
(Yes / No)

Medications if any during this hospit alization _____________ \-'- ____________________________________________

'-- "",,-

/J .:

~---- -'-------------- __

Relevant Clinica l Findings: __ __'~-' __ --:.. __ _'_ __ ~ _______________________________________________________

-Investigations Report (if any): ~
Proposed Line of Treatment:
Details of treatment received!

_______________ .:... ______________________________

...,.-------------- --

__' __________________________ _,_- ....:.---

____________________________ ~ ____________ -:-- __ .... ,.. ________ ------'--------_ :___' _ __' _____________________ -'--'- _______ -'-' ____________ ..:...., __________ __' _______________ -'- __

Estimate of Exp ~~eS:TotaIAmou~t -'-~. Class of accommodation: __

Expense: Head

...:.. ___________________________________________________

Amount

Expense: Head

Amount (Rs.)

(Rs.) .

'-

ROOM RENT

---~-

'-

INVESTIGAT IONS
...

DOCTOR / CONSULTANT VISIT CHARGES

MEDICINES/CONSUMABLES .

SURGEON CHARGgs
.'

OPERATION THEATRE CHARGES

EQUIPMENT/MONITOR ETC
MISCE UANEOUS (SPECIFY) ..

I haw completed rhis (onTi : II1J will be responsible for correctness of till: me .. licll! infclml;uio,l certified b)' m<'.

Signature of poet o r:

""l";-"''''T ft-rT ''TJ r

r-, r """<: -TTP "-'l'

. Tf'l"" )I'::' 0T:l"; "TC'TTnT ;''' !'t:

.Contact No: ~ .____________ ~ _________ _

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