Good Health Plan Limited

Plot no-49,Nagarjuna Hills

Hyderabad-500082

Phone: 1860 4253232 Fax: 1860 4254242

WITHOUT PREJUDICE

HOSPITALISATION CLAIM FORM

Issuance of this form does not account to admission of any liability under the claim on the part of the insurers

Patient Information Policy Holder Information Card ID Name Name Address Age Relationship to Insured Insurer Contact no Policy No E Mail Id Member covered since Period To Hospital / Provider name Provider code

Information on Illness / Injury and Treatment

Ailment / injury for which the member was treated Date of admission Time of admission AM/PM Date of discharge Time of discharge AM/PM

Principal Diagnosis

Other Diagnosis Medico legal Yes/No Road Accident Yes/No

Disease code (1C0)

First occurrence (Patient known to have this condition since)

Line of Treatment (Procedure done)

Procedure code (CPT) Treating doctor details Name: Qualification:

Phone no: Reg no:

Bank Account Details - This information is mandatory for customers of Oriental Insurance Co. Ltd Name of Account Holder IFSC Code

Bank name Account Type (Savings/Current)

Full Bank Account number(Without /,- or any special characters)

Bank Address Mobile Number

Note 1- The Account should be in name of Employee. Note 2-Please attach a photocopy of cancelled cheque leaf relating to this account. Treatment cost

S.No Service Description Amount Charged

Discount Net

Amount

Patient Paid

Amount

Balance Due

Remarks

1 Room Charges 2 ICU/IICU/Nursery charges 3 Doctor's Fee 4 Lab Investigation 5 Radiology 6 Other Investigation 7 Special Procedure 8 Pharmacy Service 9 OT/ Labour Room Service

10 Others (PI specify) 11 Total amount claimed

UNDERTAKING BY THE PATIENT: I hereby warrant the truth of the foregoing particulars in every respect& I agree that if I have made or shall make any false or untrue statement, suppression or concealment my right to claim reimbursement of the expenses shall be absolutely forfeited.

I also authorize the hospital/provider to submit the attested Indoor Case Papers (Case sheets) and any other documents Or information related to my treatment to GHPL if asked for.

I further declare that in respect of the above treatment no benefits are admissible under any other Medical Scheme or Insurance.

I hereby confirm that I am making no other insurance claim for the event claimed by me under this policy.

Provider Representative

Policy Holder/Patient

Name:

Name: Date:

Date:

Signature

_____________________

Signature

________________

Check list of documents

Consolidated final hospitalization bill with cash paid receipt (stamped) in original

Consultation bills with Receipt in original

Break up of hospitalization bill (Detailed bill) in original

Pre authorisation / First Admission Report in original

If Surgery is involved, Surgery bills / OT receipt in original

Copy of photo identity of the patient (if patient is a dependent) and the insured employee

Pharmacy Bills with prescriptions in original

Service line Information

Discharge Summary in original

Other bills, receipts and reports in original

Investigation Reports in original

Comments/Remarks

Photo Copy of a cancelled cheque leaf