GOOD HEALTH PLAN LTD (CHECK LIST OF MANDATORY DOCUMENTS TO BE COLECTED WITH CLAIM, (To be filled in Triplicate one copy to be given to client one copy with Claim files one copy with person preparing the checklist) BRANCH, | HELP DESK AT. DATE OF COLLECTION: TIME. NO OF DOCUMENTS ATTACHED.....(please mention no only) Documents needed YES/NO Remarks ‘Claim form filled in fal Photo Copy of ID card Proof of address if claim is more than > Rs 1.00 000 Photo copy of cancelled cheque leaf. (it should contain IFSC code , A/ eno along with name ofthe insured on cheque Incase if name is not printed same must be signed by the insured. Cheques should be of Primary policy holder only) Discharge summary in or ‘Consolidated bill issued by hospital in original Bill break up with full details charged in original ‘Cash receipt duly numbered in original Pharmacy bills along with Doctor prescription in original Investigating reports and bill in original with Doctor prescription ‘ROAD TRAFFIC ACCIDENT CASE FIR mic (Original leter from doctor mentioning the alcoholic history atthe time of Incident if ay. Circumstances ofthe accident =P PP ES EEPPS Pe 32. | Maternity claims — Obstetric history(GPLA status)/Ante Natal Scan Report in original 33 _| Cataract claim = Scan report and 1OL sticker in original 114 | Implants — original invoice in case of stunts -PHS ete 15 | Surgical packages ~ detailed break up of charges 16 | Death eases of Insured — Legal hair and No objection certificate from other legal heirs 17 | Reasons for delay in submission/non intimation if any. PLEASE NOTE THAT GHPL HAS THE RIGHT TO ASK FOR ADDITIONAL DOCUMENTS AND INFORMATION ON DETAILED STUDY OF THE CLAIM ‘Accepted by: Name of Employee. Signature..Good Health Plan Limited Plot no-49,Nagarjuna Hills, Hyderabad-500082 i Phone: 1860 4253232 Fax: 1860 4254242 WITHOUT PREJUDICE HOSPITALISATION CLAIM FORM Issuance ofthis form does not amount 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 EMail id | Member covered since Period To Hospital / Provider name Provider code Information on illness / Injury and Treatment ‘Ailment / injury for whichthe member was treated | Date of admission Time of admission am/em, | Date of discharge Time of discharge am/PM Prine i Other Diagnosis legal Yes/No Road Accident Yes/No First ocurrence_ (Patient known te have this condition since) Disease code (1€0) 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 United india insurance Co.Ltd Name of Account Holder Mobile number IFSC Code Bank name ‘Account Type (Savings/Current) |FullBank Account number( Without / or any special character) | 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 Page 1 of 2Treatment cost Amount Disco Net Patient Paid Balance Charged unt Amount Amount Due S.No Service Description 1 2 3 4 5 6 7 Remarks Room Charges ICU/MICU/Nursery charges Doctor's Fee Lab Investigation Radiology Other investigation Special Procedure 9 OT/ Labour Room Service 10 Others (P specify) 11 Total amount claimed UNDERTAKING BY THE PATIENT: thereby warrant the truth of the foregoing particulars in every respect& I agree that if | have made or shall make any false or untrue statement, suppression or concealmentmy right to claimreimbursement of | 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. | further declare that in respect of the above treatment no benefits are admissible under any other "here by confirm that | 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 Consultation bills with Receipt in | cash paid receipt (stamped) in original original Break up of hospitalization bill (Detailed bil) Pre authorisation / First Admission in original Report in original If Surgery is involved, Surgery bills / OT Copy of photo identity of the patient receipt in original (if patient is a dependent) and the Pharmacy Bills with prescriptions in original Service line Information Discharge Summary in original Other bills, receipts and reports in Investigation Reports in original Comments/Remarks Photo Copy of a cancelled cheque leaf Page 2 of 2