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9269644E
Ht-NtA-000848762
CHAKKAIIIADATHIL
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HOUSE Policy
Patient #
#
oooo722944
ft\
THRISSUR
)
BiI# o06129
Admission Date Bifl Date 23/oa/20!s
: 22/o,/2otg tLt3gtLg
AM IP# 9a57
S '1t" :araro"r2olg lrco:33 AM Doctor
UDAYKUMAR GOPINATHAN

! ADMISSION
ANAESTHOLOGISTS FEE 100.00
ASSISTANT FEE 6100.00
CLEANING & LAUNDRY 7800.o0
CONSUMABLES 100.00
6 DOCTOR'S FEE 500.oo
7 DRUG CHARGES 200.00
a 90.oo
. , E.C.c
EQUIPMENT CHARGES
. 200.00
1o INJECTION CHARGES 3500.00
!L TAB9RATORY 120.00
MEDICINE CHARGE 2190.00
'!4 MONITOR 407 !.29
RECOVERY 300.00

io
noou nerur
SURGEON'S FEE
fe4ft d t) 500.00
2250.00
4-l
THEATRE CHARGES 17000.00
20800.00
NetTotal
Sixty Five Thousand Eight
Hundrcd fwenty One And paise
Twenty

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 Cashl€ss Authorization L€tter

(Part-D) ffifl;",.;.lt'l"tl
Claim_Number: Ht-NtA-000S48762(0) (ptease quote
corresPoncl€ncel
this numb€r for atl Dare:
Authorization is v;tid foradmission up to 23/08/2019 23t0at2019

NI HOSPITAL PVI LTD

t'lmeoottnsrcne Cc: .hiie. rnaa r*re ";m y

nakaEn Nambiar Rd Aswani

NAME: AQUIry SOLUTIONS INDIA PR]VATE
D
nciion,,Pahurarhtat,Thnssur Korata,68

ini ld: 8900080226076 il:""J.'^i*,"t"3liHeFJT'JeH"',ii_i"^l'*"**

ds oi,.- i;,"n, o2bo6aaE
il:y;Tj:ji#i*X**
Dear Sir/ Madam,
ThiShas reference to the pre-authonzalion
reou submitted on 23108/2019 we hefeby authorize
lasnress rac ry as perdetaits menrioned beto.ist

Name: sneleEv c sntEEFIMf

Number. 140I04341go4ooooaoit
erpectea pate or aomesoi: -)TboDbr s
Poticy penod: 07 toit Gs4EtaTDo2o
l

rine or rreatmentMadl;r ta
Aulho4zation Detaits:-
Rererence Numbt
1916.23:13
.2310812019
Hr-N14-000848762_1
0q0 AL lssred
l6:23:i3
itinz : Ar rssuea
Totaf Authorized Amountr Rs. 47747.AO

l;[Tr;;dit#in!i@ed uc,ed c,a m

Hosoital Aqreed Tartff :,

l. Non-package case:-

. Room Renvday :2250

i rcU R€nt/day :0
ii, Nursing Charses/dav r0
v. consurrant vrsii cha.o;t;; :0
 .i. s-se"; f*/or/A";"thtisf ;o
v. OiheB (specrt) :o

:(lNR)65281.00
:(lNR)17534.00
r (lNR)47747.00
r(lNR)17534.00

Deduciion Reason
17o prcpoftionate B.5124fdeducted excess room rs 250/- j

r7534.00 7747.0Q
c aim willbe sstred as peraqreed rar ff lpi.tage
panoplaty 43700+ medic ne 35lt+room
rvesligaiion 2390)

Terms and Conditions of Authorization:

Cas!"s6u,o"zdiont.-..'ssFdontood<(o lbTauonpo,oN l Dr€- A .r o. a. o . .on k k.e

nrl6plgse||d|o'Vcoi(€are1lol.t6,a1sa.?Tcle1ao'fi6tncelde]iatbr'd('eoa1r/
dFclaJqc*nra4/loDF.oderh6rcri.<sauhouaxor.-Jt:donLt3r'od.Ardn/po.o.d"r
or-ba esede. righ,lo'.>eoLe i€. io' a-jl o rr ooc ,red lo.:@rsi, aor*u,r,vo.iri r
KYc 'K' ow lo r crdorfl, @la k ot prooose/erptof. B"r cr c'"D a€ nsrdd o1 tca,npa/o, r"bo.6 R< I d..
Nekrlpbvid€'-hd{rcrrctdatrdddilionaranorl.rrcnu-erdvbl:tn"*es,orrq,"";6".."qe

-/-ero,€4trn'heoeooEira.o. 1sleo","p..(..oM,ds
ro.adn$bearo.EI d-orqado o o qhighd.61,-.r1c1€rqo q .t. q p
orreamenrM(n E 'dtchargo.
env eagad/consdered '€rooo
n pacraae) "ein6
^or 1o aoaroddao(1 tof qd o r1a
'.1'edrlpi+. otrodrood.
anr e
altoitsdTPA,rn.Lra'kconpar\Fsoae,lte-sl o..co\erfesan6o.oe|he)a1.6.L.ddoon(oo.!.oder
no t lhe \ei*n* o'o.ider ab o
,reearoatre'uDo@dr€h.obednedoLolado.olngeo.of,ruredscFoi.L,areTd-"eo^1u-.oo6t,
NeMl pbvidq nay 9ne reaTelLaldobtaining >pe-ij..o, qe?ro poticylotd.r.
Dtr'alacoeEbon6ovmicynokdra,o"'-io,jeooyr.r'"'.s-oibrh"b,.,".dud.... reD o

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SIJPPORT OF THE CLAIM

D€iaion Discharce Summary and aLlBts frcn thehosojtal

Daarcn--€i qepoa.-d cs6oL,Lopoleo o. nor ao- heaha drcM"d€ p?(ro1-. suqeo. p. ,.-di!
suo u a!"oj L suppo.* br -o e ior l,E an8-d "s Vedi€tpa-ioner $'geon For reldi1g s r. dbqnor.lesh.
Pra j tio' - Srrseon!, rs oaxenrs (o' o I o- a.a cdnG or drr. a!-
Nekdp@viderslalno'ra(e..yem,")lon.Edeoo"rcnot'ldeaedlom.het,rlrcd.!Fp.oror-ro€ds
gadd lblcl!her!6q drA o oD.,91igrr r@n r 1d al eta o rv .\o6in9 .-p"? - ir6
>-ol€-ysag6d/@ s d€ ed r p:<.aqe r

Not€: As pef [,lodified Guidelines on slandafds and benchmarks for hospitats in the provider r\erworK
' rssued by iRDAI vide circutar Ref.tRDA /HLT/REGlGDLh14t07DAft dated2Tth Jutv 2O18.vol
hospiialis nandaionly required to registerwith ROHtNt and obtain eilher pre-entry tevetcei ficate
1or
high€rl-Avelof cedificate) issued by NABH of state levetcedificaie (or higher tevetof cedificater !noer
NOAS, issued by national Healih systems Resoufces Centre (NHSRC) on of before Ju v26. 2019.

laq94jh:etrlrodugt and ulN N ondirions (sub]imirs/co-

Dav/decluctible etc)

Authorized signatory:
(lnsu rerlTPA)