QH ospital Intimation Form Annexure by P642F6


									                                                                                  Form No HI/CLMINT/1

                                           Health Insurance, Central Office, HYDERABAD

                                           Hospitalisation Intimation          Form      under     health
                                           insurance policy

 POINTS TO BE NOTED:                                                               Annexure ‘Q’
  To be filled in by Policy holder only.
  Only the person entitled to receive the policy monies as stated under the Policy should fill and sign
    this form.
  Please feel free to insert separate sheet if the space provided is found insufficient.
  Please submit this form to the nearest office of your TPA along with the requirements mentioned

                                       Documents to be submitted
Photocopy of Policy Certificate
Claimant’s Statement Form (this format)
Photo Identity & address proof of the claimant with the claimant’s signature on the backside of the both
Attending Physician’s Certificate
Any other document as stated in the policy document
Please provide any other relevant support document for faster processing of claim. The TPA may call for
additional documents / requirements if needed.

 1.   Life Assured Details:                          Policy No: ________________

      1   Full Name
      2   Date of Birth                  DD / MM / YYYY
      3   Communication Address

          Telephone Number               (STD Code) (Telephone Number)
          Mobile number

 2.   Details of the Beneficiary for whom the claim is preferred

  Name of the Member for whom the
  claim is preferred
  Relationship                                                                 Sex
  Date of Birth                                                                Age      DD/ MM/ YYYY
  Nature of Illness
  Date of onset of illness
  Hospital details

 Signature of the Policy Holder
 This Form is to be submitted to the TPA along with the Medical Certificate (Page 2)
   Name of the TPA
                                                                               Form No HI/CLMINT/1

   Name of the Patient & Age
   Photograph of the Patient to be
   pasted here
   (Xerox of the Health card also can be
   pasted here)

   Hospital Certification
   The person whose photograph is affixed above has availed the medical treatment in the hospital

                                           Treatment Particulars

   1.   Date of Admission                                 Date of Discharge

   2.   Name of Surgeon / Physician
   3.   Diagnosis
   4.   Date of first consultation
        (Prior to hospitalisation)
   5.   (a) With what complaints was the patient
        admitted for:
        (b) Since when was the patient suffering from
        the said complaints
   6.   Past History of the Patient (if any) with the
        duration of illness
   7.   Whether the present ailment is a complication
        of Pre-existing disease?
        If yes, please specify the disease (or)
        complication of any previous Surgery done?
        If yes, please specify details.
   8.  Whether the disease/disorder is congenital in
   9. Nature of Surgery/treatment given for present
   10. (a) Whether Hospital/Nursing Home is
       Registered, if yes, Regn. No.
       (b) No. of in-patient beds in the Hospital
       (including ICU)
        (c) Whether the hospital is having fully
        equipped Operation Theatre of its own/
        qualified nurses Round the clock / Qualified
        doctors round the clock?

Signature of the Doctor with seal                                      Date:

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