DHS

Dedicated Healthcare Services

(India) Private Limited
Corporate Office :
Office No 18 , 2nd Floor
Khetan Bhavan,

IRDA License No 28
Tel No. :022-22795900
Fax
:022-22874235

J. Tata Road,Churchgate,
Mumbai 400 020.

Email id contactus@dhs-india.com

Admission Request Note

Name of the Proposer :________________________________________________________________________
Name of the Patient: _________________________________
Age: ____________ Sex_______________
Telephone / Mobile No: ________________________________
Name of Hospital / Nursing Home: ______________________________________________________________
Present Complaints: _______________________________________________________________________
History of the present complaints: _______________________________________________________________
Duration of present complaints: ________________________________________________________________
Relevant past history and treatment: _______________________________________________________________
Investigation Reports (attach separate sheet)
Provisional/ Differential diagnosis ________________________________________________________________
Proposed Treatment Plan (attach separate sheet): __________________________________________________
Particulars

Yes/No

Since
When

Hypertension
Diabetes
Alcohol/ Drug abuse
In c/o Accidents, influence of alcohol / drugs:
Yes / No.
Whether MLC done: Yes / No
Particulars
Probable Date of Admission
Approximate duration of stay
Room Rent with Class / ICU Charges
Investigation Charges
Doctor/ Surgeon Fees
Other Charges
Approximate Total Expenses
Package Rate

Particulars
Heart Diseases
Any other Chronic Disorder
Please specify
------------------------------------------------------------------------------------------

Yes/No

Since When

Details

PART II to be filled in by the Hospital Authorities:

DHS will not be held liable for the payment in the event of any discrepancy between the facts presented at the
time of admission and in the final documents submitted.
Name and Designation of treating Doctor: _________________________________ Signature: ____________
Rubber Stamp of the hospital: __________________ _______________
PART III- To be filled in up by the insured
I have no objection if DHS obtains details of my treatment / collects documents and I also hereby authorize DHS to pay the hospital bill & receive
the amount of my claim from my insurance company. If my claim is rejected, I/ We (the patient) will pay for the hospital and related expenses
should this authorization become null and void due to wrong and/or misleading and /or incorrect information regarding the duration of ailments
and/or other historical information regarding my (patients) health status. I agree that information provided by me is true to the best of my
knowledge.

Id No: ______________________________

Policy No: _______________________________

Insurance company: ____________________________________________________________

Signature: _________________________
Date: ____________________________

Name: __________________________________