Professional Documents
Culture Documents
Medi Assist
a) Policy No.:
SECTION A
d) Name:
e) Address:
City:
State:
Pin Code
Phone No:
Email ID:
Yes
No
Date:
Policy No.
Yes
d) Have you been hospitalized in the last four years since inception of the contract?
No
Diagnosis:
Yes
No
SECTION B
a) Name:
b) Gender
Male
Female
Self
f) Occupation
Self Employed
Spouse
Child
Home Maker
Months M
d) Date of Birth
D
Y
Father
Mother
Other
(Please Specify)
Student
Retired
Other
(Please Specify)
SECTION C
F
Y
c) Age years
City:
State:
Pin Code
Phone No:
Email ID:
DETAILS OF HOSPITALIZATION:
Injury
e) Date of Admission:
Single occupancy
Illness
f) Time
Twin sharing
Maternity
H
g) Date of Discharge: D
Yes
No
I) If Medico legal
Rs.
Rs.
v. Ambulance Charges:
Rs.
Rs.
No
Rs.
iv. Convalescence:
Rs.
vi. Others:
Rs.
Total
Rs.
Issued by
Towards
2.
Pre-hospitalization Bills:
3.
Post-hospitalization Bills:
4.
Pharmacy Bills
6.
8.
9.
10.
Amount (Rs)
Nos
Nos
SECTION G
7.
No
SECTION F
OperationTheater Notes
ECG
Doctors request for investigation
Investigation Reports (Including CT
/ MRI / USG / HPE)
Doctors Prescriptions
Others
1.
5.
Pharmacy Bill
Date
Y
H
Rs.
Yes
Y
H
M
h) Time:
b) Account Number:
Place:
SECTION H
SECTION E
Total
b) Claim for Domiciliary Hospitalization:
M
Y
days
j) System of Medicine:
Rs.
DETAILS OF CLAIM:
SECTION D
GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT
DESCRIPTION
FORMAT
Policy No.
b)
c)
d)
Name
e)
Address
Tick Yes or No
b)
Use dd-mm-yy-forrmat
c)
Company Name
Policy No.
Sum insured
In rupees
Tick Yes or No
Date
Diagnosis
Previously covered by any other Mediclaim / Health
Insurance?
Company Name
Open Text
d)
e)
f)
Tick Yes or No
Name of the organization in full
Name
b)
Gender
c)
Age
d)
Date of Birth
e)
f)
Occupation
g)
Address
h)
Phone No
1)
E-mail ID
b)
c)
Hospitalization due to
d)
Date of admission
e)
f)
Time
g)
Date of discharge
h)
Time
I)
If Medico legal
Tick Yes or No
Reported to Police
Tick Yes or No
Tick Yes or No
System of Medicene
Open Text
j)
b)
Tick Yes or No
c)
d)
PAN
b)
Account Number
c)
c)
c)
IFSC Code
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
DETAILS OF HOSPITAL
a) Name of the hospital:
c) Type of Hospital:
e) Qualification:
Network
Non Network
SECTION A
b) Hospital ID:
g) Phone No.
b) IP Registration Number:
c) Gender:
f) Date of Admission:
j) Type of Admission:
Emergency
Planned
Discharge to home
g) Time:
Day Care
Male
H
Female
d) Age: Years Y
h) Date of Discharge:
k) If Maternity
Maternity
Months M
i ) Time:
i. Date of Delivery: D
Deceased
e) Date of birth: D
SECTION B
ICD 10 Codes
ICD 10 PCS
b)
Description
i. Procedure 1:
ii. Procedure 2:
iii. Co-morbidities:
iii. Procedure 3:
iv. Co-morbidities:
d) Pre-authorization obtained:
Yes
No
SECTION C
i. Primary Diagnosis:
Description
e) Pre-authorization Number:
Yes
No
Self-inflicted
ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this:
v. FIR no.
Yes
Yes
No
Yes
No
Investigation reports
CT/MR/USG/HPE investigation reports
ECG
Pharmacy bills
SECTION D
State:
Pin Code:
b)Phone No.
d) Hospital PAN:
i. OT :
Yes
No
ii. ICU :
Yes
No
SECTION E
City:
iii. Others :
Date:
Place:
SECTION F
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact,
our right to claim under this claim shall be forfeited.
GUIDANCE FOR FILLING CLAIM FORM PART B (To be filled in by the hospital)
DATA ELEMENT
DESCRIPTION
FORMAT
Name of Hospital
b)
Hospital ID
c)
Type of Hospital
d)
e)
Qualification
f)
g)
Phone No.
Name of Patient
b)
IP Registration Number
c)
Gender
d)
Age
e)
Date of Birth
f)
Date of Admission
g)
Time
h)
Date of Discharge
i)
Time
j)
Type of Admission
k)
If Maternity
Date of Delivery
Gravida Status
l)
m)
ICD 10 Code
Enter the ICD 10 Code and description of the primary
diagnosis
Enter the ICD 10 Code and description of the additional
diagnosis
Enter the ICD 10 Code and description of the co-morbidities
Primary Diagnosis
Additional Diagnosis
Co-morbidities
b)
ICD 10 PCS
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
Open text
c)
Pre-authorization obtained
Tick Yes or No
d)
e)
Pre-authorization Number
If authorization by network hospital not obtained, give
reason
Hospitalization due to injury
As allotted by TPA
Open text
Tick Yes or No
Cause
If injury due to substance abuse/alcohol consumption,
test conducted to establish this
Medico Legal
Tick Yes or No
Tick Yes or No
Reported To Police
Tick Yes or No
FIR No.
Open Text
f)
Address
b)
Phone No.
c)
d)
Hospital PAN
e)
Digits
f)