CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL Tse ofthis Forms ret bette a an asin oad Peat ncude te orga preautaizaon quest Fom ine of PART A (Tobe edn Bock eters) DETAILS OF HOSPITAL ajnomeorinerosetat: [TT TTTTTTTT TTT TT TT rrr rr rrr rrr iri rit tt itt) »)Mosptto CECI) —— ot rretrospiat: newt] Nonnewonc [-] _ on nator seten 6) anerne ote watnacoeor: [TsTuTeINTaMPeD TTT Tr Test Te TT oe Ter eae) ©) uatteston a ee | DETAILS OF THE PATIENT ADMITTED ainaneotteraset: CEE EER EE TTT TCT EET EGET Eee EE) 1) Regisraton nomber: TT TT LTT] «) cener: nato[]Fomatel_] oe: Year [| Mots[ J] one ote DT] poawotrdnieson: §— EDIE MICD ome SIE] orci: IOC ome OO oo DTypwatAdmison: ——eereno[_] rmol_] ooycasl] waer/[] nenienty ome croeven: [To] oDTILEIL] wee sine T 1 Situs attine of cecarge: Dachagetohome [] Dicargtoancterhoepal [] Deceseed [] mp Tort esmedamoun’ [TTT TT] DETAILS OF AILMENT DIAGNOSED (PRIMARY) a 100 10.Codes Deserston » 10 t0Pcs Descriion | Primary Diagnosis | Procedure 4 1. Addons! Diagnose | Procedure 2: i, Comoridios i Prececure 3 Iu Commorbicos Iv etal of Procadice )Pre-autoraton obtained: []¥es []No ey Preautorsaton nonber: [TTT TITTITIITIITIT LL o)atorason by stworkhosptal nat otne, hereon: [Sd ‘pHosptakzaon due winiay: [ves [Jno itves. give cause Saniced [] Road Trafc Acident[] Substance abuse cohol consumston |] thu aun o Substance butlacohl consumption, Test Conduct eatbih i: []ves []No (Fes atach oper). Meco tea: []ves []no weromntraice: vee pe ee CECE) fot reported to police give reason 1 (CLAIM DOCUMENTS SUBMITTED - CHECK LIST (lain Form duty signed Cigna Pre-autoreation request Copy ofthe Pre-authrzation approval eter Copy of phot ID card of patent veri by hospital Hospital Discharge Summary Investigation reports CCTIMRIUSGMPE ivesigaton repens Doctor's refernce sip fr investition ee Pharmacy bis MLC ropes & Pole FIR tiga death summery rom hosp where applleable Any ote, lease specty Hospital man bi oooo0o0o0o00 ooo00o0000 Hospital breakup bi ADDITIONAL DETAILS IN CASE OF NON-NETWORK HOSPITAL (ONLY FILL IN GASE OF NON-NETWORK HOSPITAL) 8) Across of the Hospital CLIT iat [ateie(e eel U1 CLLETT TI CLLLEIT) LT GE 00: EE oo: EE 2.000: EE © ious: I vxous3s I I TTI I I I TTI Oly: I TITTTTT TL) ss [ LT Pin Code vy Prone no-[ TT TT TT T_]) Registration No. with State Codd: 6) Hosp PAN CECI) oeveratipatervese: TT] ‘Facies avableinthehowptot 07: [-]ves[ Jo tc: []ves []no i ober: [ 1 DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY) ‘We horeby dca tha he infrmation fumishd hi Cam Forms tr & comec fo the bes of our knowlege & belt we have made any fle or untrue statement "ipproseon or concesment of any mater fact. ur right lim under th clam shal be foreleg oe: ERIRNIEM Is xousas race: [Crate ac oft Hostal tery