HDFC ERGO General Insurance Company Limited HDFC

ERGO
REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH
INSURANCE Talea it aay!
POLICY PART - C
only)
DE TAILS OF THE THIRD PARIY ADMINIS IRATOR/ INSURER HOSPIIAL (Al fields aro mandatory and fill in CAPITALS
a) Name of the TPAW Insuranco Company HDFC ERGO Gonoral Insuranco Company Limitod

b) Customer service no 022- 6234 6234 / 0120- 6234 6234

c) Name of Hospital
I Address Nuwsnag Moe
. Rohini ID
F-mad d

TO BE FILLED BY INSURED/ PATIENT

a) Name of the Patient

(Middle Name) Last Narre)
(First Name)

b) Gender Malo c) Age years Months d) Date of birth:

Female Thitd Gender

e) Contac Number ) Contact number of atlending relative

g) nsured Member lD card No h) Policy No /Name of Corporato.

) Emplovee ID

)Currently do you have any Medicdham Health Insurance Yes No

i) Company Name

u) Gve details

IDo you have a family physician Ye: No ) Name of the family physician
m) Contact No if any

n) Current Address of
Insured Patent

o) Occupation of Insured Patent

(PLEASE COMPLETE DECLARATION OF THIS FORM)

TO BE FILLED BY TREATING DOGTOR/HOSPITAL

a) Name of the Treatng Doctor b) Contact Number

c) Nature of illness/ Disease with d) Relevant clinical findings

presenting complaints

kge
e) Duraton of present ailment Days i) Date of first consultation ) Past history of present
ailment, if any

) Provisional DiagnosIS
i) ICD Code.

g) Proposed line of treatment V)Medical Management i) Surgical Management ii) Intensive Care iv) Investigaion v) Non allopathic treatment

h) If investiga tional &/ot Medical ) Route of drug administration

Management provide detais
i) ICD 10 PCS code
I) If surgical name of surgery

i) lfother treatment provide k) How did injury occur

details

I) In case of Accident LIs it RTA Yes V ii. Date of injury: . Reported to police. Yes No iv. FIR No

v) Injury/Disease caused due to substance abuselakcohol consumpltion Yes No vi) Test conducted to establish this Yes No (lf yes, atach report)
m) In case of Maternity G

i) Expected date of Delivery

Details of patient admitted
a) Date of admission b) Date of Time d) Mandatory Past history of any chronic lness
If yes, since (monthyear)
c) Is this a emergencyla planned hospitalisation event? Emergency Planned
i) Diabetes
e) Expected No. of days stay in hospital Days
) Heart Disease
) Days in ICU. Days o) Room Type
w) Hypertension
h) Per Day Room Rent + Nursing &Service Charges + Patient's Diet Rs
iv) Hyperlpidemias
I)Expected cost for investigalion +dlagnostics Rs
v) Osteoarthritis
) ICU Charges Rs
i) Asthmal COPD/ Bronchtis
k) OT Charges Rs
vi) Cancer
I) Professional fees Surgeon +Anesthetist Fees + consullalion Charges Rs
vii) Alcohol or drug abuse
m) Medicines +Consumables +Cost of Imolants (if applicable please specify). Rs
ix) Any HIV or STD /Related aments
n) Other hospital expenses if any Rs
x) Any other Ailment give details
o) All indusive package charges if any applicable Rs.
p) Surn Total expected cost of hospitalization Rs

HDFC ERGO General Insurance Company Lirmited (Formetty HDFC Genetal lnsurance Linited) Registered &Corporate 0ffce 1st Eloor HDFC House 165-166 Backbay Redamaton, H IParekh Mang. Churchgate
IMurmba - 400 020 Customer Service Address D301, 3rd floor, Eastern Business Dstrict (Magnet Mal), LBS Marg, Bhandup (West). Mumbai -400 078 Customer Servce No 022 -6234 6234 /0120- 6234 62
care@hdfcergo com <www hdtcergo com Trade Logo displayed above belongsto HDFCLId and ERGO Inlernational AGand usedby the Company under icense CIN U66030MH2007PLC17717. IRDATReg No 120
 DECLARATION (Please read carefuly)
We confirm having read understood and agreed to the declarations of this form
a) Name of the treating doctor e JAMAL A KMAN
b) Qualification M S MO c) Registration No. with state code:

urs
Dr. AMALAKHAN
Hosptal Soal(Must Incube Hospilat1b) Patient/ Insured Name &Signature
M.B.B.S., MD
NsoaMDECLARATIONBY THE PATIENT/REPRESENTATIVE
lagree to allow the hospital to submil al original docurments pertaining to hospitalization to the Insurer/T.P.A after the discharge. Iagree to sign on the Final Bil &
the Discharge Summary, before my discharge.
Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer /TPA is not liable to settle the hospital bil, iundertake to settle the biH
as per the terms and conditions of the policy,
authorized by the insurer/TPA n
All non-medical expenses and exper
governed by the torme
s not reley
d Uons othe oeevat l0 curernt nospitalzation and the amounts over & above the limit
policy will be paid by me
Thereby declare to abide by the terms and conditions of the policyand if at any time the facts disclosed by me are found to be false or incorrect Iforfeit my claim and
agree Ooemniiy
agtee to in the Insurer
e. lagree and understand that TP.Ais in no way warranting the servce of the hospital &that the Insurer /TPAis in no way guaranteeing that the services provided by
the hospital will be of a particular quality or standard.
f. Ihereby warrant the truth of the forgoing particulars in every respect andlagree that if Ihave made or shall make any faBse or untrue staternent, suppression or
concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited.
9 lagree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA.
h "/We authorize Insurance Company/TPA lo contact melus through mobilelemail for any update on this claim

Patient's/ Insured's Name:

Contact No. E-mail ld (optional):

Patient's/ Insured's Signature:

Date: Time

HOSPITAL DECLARATIONshars
We have no objection to any authorized TPA/ Insurance Company official verifying documents pertaining to hospitalization.
Aillvalid original documents duly countersigned by the insured/patient as per the checklist below will be sent to TPA/ Insurance Company within 7 days of the
patient's discharge.
We agree that TPA/insurance Company willnot be liable to make the payment in the between the facts in this form and discharge summary or other documents
d. The patient declaration has been signed by the patient or by his represenlative in our presence
e. We agree to provide clarifications for ihe queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications
We will abide by the terms and conditions agreed in the MOU
9. We confirm that no additional amount would be collected from the insured in excess of Agreed Package Rates except costs towards non-admissible amounts
(incuding additional charges due to opting higher room rent than eligibility/choosing separale line of treatment which is not envisaged/considered in package).
h. We confirm that no recoveries would be made from the deposit amount collectedfrom the Insured except for costs towards non-admissible amounts (including
additional charges due to opling higher room rent than eligibility/ choosing separale line of trealment which is nol envisaged/considered in package).
In the event of unauthorized recovery of any addilional anount from the Insured in excess of Agreed Package Rates, the authorized TPA/ Insurance Company
reserves Ihe right to recover the same from us (the Network Provider) and/or take necessary action, as provided under the MOU or appiicable laws.

JAMALA KHAN
S. MD

Hospital Seal Doctor's Signature

Date: Time:

Rackbay Reclamatorn H I Parekh Mag Curchgae,

Iosurance Limited) Registered 8 Corpotate ofMce tst Fky HDEC Heuse 165.16e 0120 - 6234 6234|
HDFCERGO General Insurance Company Limited (Formerly HDFC General . Bhandup (West), Mumba 400 078 Customer Servce No 022- 6234 6234
IRDAIReg No 146
Mumbai - 400 020. Customer Service Addross. D-301, 3rd Fkoor, Eastern Business District (Magnet Mal). LBS CIN U6030420PLC17711?
care@hdfcergo.com www.hdfcergo.com. Trade Logo dispBayed above belongs to HDFC Ltd end ERGO Internation nai AGandused by the CeComyany under lcense