HOSPITALIZATION FOR MEDICAL

INSURANCE Poucy
REQUEST FOR CASHLESS
IFFCO TOKIO GENERAL
INSURANCE COMPANY LIMITED

CIN: VZ4899DL2000PACI07621
IFFCO-TOIO
MUSkutate kaho

a) Name of TPA:
Insurance company: d) Toll free Fax:
b) Name of
number:
)Toll free phone
e) E-Mai ID

la) Namc of Insurcd

o) Name of the Patient:
I A T I I o) Relationship jÍ Prlgary nsured:
Male Female )Age: years ZII months S] DO8: Soe Contact No:
c) Gender DRelalonship lo palient:
e) Name of the person attending the patient:

g) Address: State:
E-Mald ID
City
Pin Code:
Phone No. HIL5324
I)Pollcy number employee/member of the roy
) Insured ID number: HILS)24 non the date of hospitalization,
YesNo
are you an
f Yes, ) Policy No.
No

k)Corporate Name
i) Policy Type: Individual JCorporate m) Currently doyou have any other
Mediclaim/Health Insurance:
nsured Rs.
m) Employee ID: ii) Sum
o) Contact Number:
ü)Company Name
n) Name of the family physician:

scheme. If ves, Give Details:

|P) Are you covered under any similar health
b)Contact Number:

findings:
d) Relevant clinical
la) Namne of the treating doctor
lc) Nature of ILLNESS / Disease
with presenting complaints
)Past history
i) Date of first consultation: of present
e) Duration of the present ailment: ailment if any:

I) ICD 10 Code:
) Provisional diagnosis: Investigation Non Allopathic treatment
Intensive care
Surgjcal Managgment
Medical Management administration:
g) Proposed line of treatrment: i) Route of drug
h) If investigation 8/ Medical
Management provide details I) ICD 10 PCS Code:

i) If Surgical, name of surgery. k) How did injury occur:

) f other treatments provide ]Yes No Fir No.

D0| |Y v) Reported to police: No (f yes, atach reports)
details: TYeso ) Date of Injury: vi) Test conducted to
establish this Yes
I) In case of accident: I) Is it RTA:
abuselalcohol consumption: yes, since month / year
caused due to substance LMP illness
v) Injury Disease P Mandatory: Past History of any chronic
) In case of Matemity:
Details of the patient admitted Diabetes
c) Room No.: TT
Heart Disease
5YIS] b) Time: Planned
a) Date of admission: Emergency Hypertension
planned hospitalization
event?:
a Days f) Room Type:
d) Is this an emergency / hospilal:
Hyperlipidemias
e) Expecled no. of days stay in Rs. Osteoarthritis
Rent: Rs Asthma / COPD / Bronchitis
g) Per Day Room
Charges + Patient's Diet: Rs
h) Nursing &Service Cancer
for investigation + diagnosics: Rs. Alcohol or drug abuse
i)Expecled cost
Rs Any HN or STD / Related ailments
i ICU Charges:
k) OT Charges: Rs Any other Ailment gve detais:
Surgeon: Rs.
)Professional fees Anesthetist:
fees Rs.
m) Professional
fees Consultation: Rs.
n) Professional Other hospital expenses
if any:
lo)
Medicines+Consumables.
Rs.
applicable please specify): Rs.
p)Cost of Implants: (f charges if any applicable: Rs
package
a)) Allinclusive hospitalizaion:
expected cost of
r) Sum Total

Hospilal!:
of the
JPin
C o d e : I | A

Name
la)
c) Address of the
Hospilal: State:
CAAÊytNA
E-Mail ID
City.
Phone No. Mobile No.

d) Name of Key Contact

person:
Reg. No. of the Doctor:
GLo ATORlestdone so far:
e) Qualification of a treating doctor:
 We confirm having read understood and agreed to the Declarations on this form
a) Name of the treating doctor:
b) Qualification
c) Registration No. with state Code:
Signaturot Patient Insured Narme & Signature:
Hospital Seal (Must include Hospital |D)

DECLARATION BY THE PAT0NT / REPRESENTATIVE Maharaia Agarsain Chartabtetuspila my discharge.

1. lagree to allow the hospità| to submit all original documents pertaining to Discharge Summary before
on the Final Bill & the
Payment to hospital is goverFed by the terms and conditions of the policy. hospiGetvitRalerosePIERARreefg sign of the policy
the terms and conditions
3. All non-medical expenses ard expenses not relevant to
urrent
In case the insurer/PAs
AWayRoad
Die o
authorized by
take to settle the bll as per
the InsurerTPA not gOverned by the terms and conditions or the pollcy wll be paid by me. In
case any clar

hospltaliaoar
is needed on admissibility ofa particular item, Ishall contact TPATollFree Number
Over B ahove the limit
Mandi (Sonipat)-13110 breit my agree to indemnify the
Insurer/TPA
4. Ihereby declare to abide by the terms and conditions of the policy and ifat any time the facts disclosed by me aref claim andd
5. lagree and understand that T. P.A is in no way waranting the service of the hospital & that the Insurer/TPA is in no way guaranteeing that the services provided by the hospital will be of a particular
quality or standard.
reimbursement of the said expenses shall be absolutely
concealment, my right to claim
6. I hereby warrant the truth of the forgoing particulars in every respect andlagree that if I have made or shall make any false or untrue statement,, suppression or
forfeited. Ifurther declare that, in respect of the above treatment, no benefits are admissible under anv other Medical Scheme or nsurance.
7.lagree to indemniy the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA.
8.lauthorize Insurer/TPA to view my medical&nursing records, investigation reports, medicines given, their bills etc.; and to collect their photocopies.

Patient's / insured's Name: Contact Number 99966347T

Patient's/ insured's signature:

HOSPITAL DECLARATION
We have no objection to any authorized TPA/ Insurance company official verifying documents pertalning to hospitalization.
will be sent to TPA/ Insurance company within 7 days of the patient's discharge.
Allvalid original documents duly countersigned by the insured / patient as per the checklist below Insurance Co, OR arising out of incorrect information in the pre-authorization
form will be collected from the
or illnesses OR expenses disallowed in the Authorization Letter of the TPA/
3. All non-medicalexpenses OR expenses not relevant to hospitalization
patient. discharge summary or other documents.
payment in the event of any discrepancy beween the facts in this form and
4. We agree thatPAL ineahse sompogy will not be liable to make the presence.
n has beerRpedy the patient or by his representative in our
5. The patiep
take the sole responsility fpr any dey i offehng clarifications.
6. We agr tooye clarificationor eeries raised regarding this hospitalization and we
|7.We wi ate the terms and condgios aÀeed in the MOU.

HospitalSel
Authorised
Gnaur
DOCUMÈ TSSO DE PROVIDED IN OPGAALp THE HOSPITAL
IN SUPPORT OF CLAIM (DURING CAIM SUBMISSION)
<<in IRDA prescribed format>>
Docor's Sig«ature

Detailed Di_ch SUOdnd aeiisfom the hospital

prescription.
Cash Memos komtle Hitals Chmists supported by proper supported by note from the attending Medical Practitioner/ Surgedn
recommending such pathological Tests.
Receipts and PathegicTeKeports from Pathologists,
operation performed and Surgeon's Bill and Receipt.
Surgeon's Certificate stating nature of
/Surgeon that the patient is fully cured.
5. Certificates from attending Medical Practitioner
 MAHARAJA AGARSEIN CHARITABLE HOSPITAL
MAHARAJA AGARSEIN CHARTABLE Opp. Police Station, Railway Road,Ganaur, Distt. Sonipat (Haryana)
HOSPTALGANAUR Ph. :0130-2463470, Mob. : 09283394470

Date:- b/o sl2s.

UHID: -MACH/2024-25/
Fsha wlo Anstuul Mobile:-949685399 7.
Name:
OPD No.: Age/Gender:- 4|E. City: Baui
Consultant:- Dr. Amit Garg (MBBS, DNB Ortho) Dept:- Ortho

BP
Pain Score:
Temp 4 10
No Hurts Hurts Hurts Hurts Hurts
Pulse Hurt Little Blt LItte More Even More Whole Lot Worst

Hefhlcim)r94 History/Chief Complaint:

Weight (Kg):
BMI Physical Findings:
Nutritional Assessment
Required Diagnosis:
Yes No Laacau dchn lou

LMP

Any Allergies:
Rx

Investigation Advised: -

Celco)

Veiw eateutf

N T VÀLID FOR ANY MEDICO-LEGAL PURPOSE

 bR.
A M I TG A R G

M.E.B.S.,D.N.B.( O r t l o )
Hospital

49008
No.
C h a r i t a b l e

Reg.
DMC
A g a r s e i n

M a h a r a j a

Auikasn

Tas Rrveonalan

Toe yuh

he foneeti DR. AMIT GARG

M.B.B.S., D.N.B. (Orho)
49008
DMCReg. No.
Chartable Hospital
Maharaja Agarsein