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 amount to admission of any liability under the claim on the part of the insurers

Patient Information
Card ID
Name
Age
Relationship to Insured
Contact no
E Mail Id
Member covered since
Hospital / Provider name
Provider code

Policy Holder Information

Name
Address
Insurer
Policy No

Information on Illness / Injury and Treatment

Ailment / injury for whichthe member was treated
Date of admission
Date of discharge
Principal Diagnosis
Other Diagnosis
Medico legal
Yes/No

To

Time of admission
Time of discharge

AM/PM
AM/PM

Road Accident

Yes/No

First occurrence (Patient known

to have this condition since)

Disease code (1C0)

Line of Treatment (Procedure done)
Procedure code (CPT)
Treating doctor details

Period

Name:
Qualification:
Phone no:
Reg no:

Bank Account Details - This information is mandatory for customers of United India Insurance Co. Ltd

Name of Account Holder

Mobile number
IFSC Code
Bank name

Account Type (Savings/Current)

Full Bank Account number(Without /,- or any

special characters)

Bank Address
Note 1- The Account should be in name of Employee / Main Member
Note 2-Please attach a photocopy of cancelled cheque leaf relating to this account
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Treatment cost
S.No

Service Description

1
2
3
4
5
6
7
8
9
10
11

Room Charges
ICU/IICU/Nursery charges
Doctor's Fee
Lab Investigation
Radiology
Other Investigation
Special Procedure
Pharmacy Service
OT/ Labour Room Service
Others (PI specify)
Total amount claimed

Amount Disco
Net
Charged unt Amount

Patient Paid
Amount

Balance
Due

Remarks

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 concealmentmy right to claimreimbursement 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 documentsOr 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 here by confirm that I am making no other insurance claim for the event claimed by me under this policy.

Provider Representative
Name:
Date:
Signature _____________________
Check list of documents
Consolidated final hospitalization bill with
cash paid receipt (stamped) in original
Break up of hospitalization bill (Detailed bill)
in original
If Surgery is involved, Surgery bills / OT
receipt in original
Pharmacy Bills with prescriptions in original
Discharge Summary in original
Investigation Reports in original

Policy Holder/Patient
Name:
Date:
Signature ________________

Consultation bills with Receipt in

original
Pre authorisation / First Admission
Report in original
Copy of photo identity of the patient
(if patient is a dependent) and the
insured
Service employee
line Information
Other bills, receipts and reports in
original
Comments/Remarks
Photo Copy of a cancelled cheque leaf
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