Star Health and Allied Insurance Company Limited

Tariff Statement - Mini SoC ( )

Hospital Name:
Hospital Address:
Owner Name:
TPA Coordinator Name: Phone No:

A Room Charges: Lab Charges

No of Room Nursing 25 Serum Creatinine
S.No. Category
Beds Rent Charge 26 Serum Electrolytes
1 General Ward 27 LFT
Semi Private Room / Sharing 28 Thyroid Function Test
2
Non A/C 29 Lipid Profile
3 Single Room Non A/C 30 Blood Widal
4 Semi Private Room A/C 31 Smear for MP and MF - QBC
5 Single Room A/C 32 Dengue NS1 Antigen
6 Deluxe Room 33 Dengue Serology
ICU Charges Including: Monitor, Pulse Oximeter, Syringe Pump & Infusion 34 CT /BT
Pump, etc.,(All Inclusive Charges / Day) 35 Prothrombin Time
7 ICU/ICCU/MICU 36 Partial Thromboplastin Time (aPTT)
8 Neonatal ICU 37 Leptospira IgG
B. Professional Charges: 38 Leptospira IgM
9 Duty Doctor / Day 39 RA Factor
10 Specialist/ Day 40 CRP
C.Operation Theatre Charges : All Inclusive 41 Blood Uric Acid
11 Operation Theatre/ Hour 42 Culture & Senstivity - Blood
D.Imaging Investigations: 43 Culture & Senstivity - Urine
12 USG - Pelvis 44 ABGA
13 USG Whole Abdomen 45 HIV I & II
14 ECG 46 HBsAg
15 ECHO 47 Mantoux
16 TMT 48 Sputum for AFB
E.Lab Charges 49 Blood Typing & Cross Matching
17 Blood Grouping And Rh Typing 50 Complete Urine Examination
18 Complete Blood Count 51 Complete Stool Examination
19 Platelet Count F.Others:
20 Haemoglobin 52 Ventilator Charges per day
21 Blood Sugar - Fasting / PP / Random 53 Dialysis Per Session
22 HbA1C 54 Blood Transfusion Charges
23 Glucose Tolerance Test 55 Registration Charges
24 Blood Urea 56 Ambulance

Note: a.) Kindly quote charges for all the facilities given above. For services / Infrastructure not available, Kindly mention ““Not Applicable “.
b.)) The Charges which are not quoted would be considered as “Not Applicable“only
“only.
c.)) The charges submitted shall be utilized to arrive
arrive at certain guideline charges and shall not be considered as agreed / accepted by us.
d)) This is valid for a period of 3 years from the date of acceptance by both the parties
parties.

For Hospital: For Star Health and Allied Insurance Co. Ltd

Name of the Designated Official:

Date:

Signature & Seal of Designated Official / Hospital