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 FAGE 2 : NOT TO BE FAXEDTSCAI-IHES

DECLARATION BY THE PATIENT / REPRESENTATIVE

befue my disctarge.

?. Pafmt b hcpitsl is governed by he terms and ordlbns of tre poky. ln case [r ln$rer l TPA b not liable to sette tre hospibl bill, I underbke to sefe he bil as per h6 tom]s atd
ondiliors of he policy.

cordilions of he polcy wif be paid by me.

4, I hereby dechte to aiide by the t6ms and cofiditiom of he poky ard il at any facb disclosed by me are found to be lalse or incorecl I forfeil my claim and agree to indemnif
he insurer / T.P"A

particular qualty or shndard.

to the daim, my r(rhl b chln reimburcem€nt of fre said expenses shall be absolutely brfuited.

7. I agree to indemni0 te hoo$tal against a[ expsEes inqrred ofl rrry behalf, wtlidr are not reimbursed by tre insurer / IPA.

a) Patents I lnsured s V IJ A Y K rJM A-2

b) Contact c) Pa[ents / lnsured's

HOSPITAL DECLARATION

1. We have no obiedion b any aulhodzed TPA I lnsurance Compary offcid vaifyirq doolrlBnb petuing to hospitalization

infoimatirn in he p{€.auhorielion bm ufl be coleded fofi the pathnt

4. WE AGREE THAT TPA/ INSURA}.ICE COMPAT.IY W[.I NOT BE LIABLE TO IJ|AKE THE PAYMENT IN lHE EVENT OF AI.IY DISCREPANCY BETWEEN THE FACTS IN THIS FORM
AND DISCHARGE SUMMARY or other docurnents.

5. The patient dechratim tns been stped by te palient or b hb represent h our pres€nce.

6. We aEee povkh darifrcation br he qcdes raised rsg8rding tris h,ospitalizalim a'd we hke he sole responsiblily for any delay in offering darificalions.

7. We wll abiJe by tE brms and condtins a$eed in he t Ot .

tlospitd Seal
& Doclor's Signature

Services &
Mul' 'JL"I Clinics lndia Pvt Ltd

Bangaiorc'- 560005.
DOCUI'ENTS TO BE PROVIDED BY THE HOSPfTAL II{ SUPPORT OF THE CLAlrI

1. Detaled Discha€e Sumrnary and a[ BiIs frcm he hospital.

2. Cash Memos from fie Hosp*tals I Chembls supported by proper prescription.

3. Receipts and Palhological Test Reports from Pa$rologisb. Suppoded by rpte fmm lhe attending Medical Practitioner / Surgeofl recomnending sud pathological Tests.

4. Surgeon's Cenmcate stating nature ofOperation perfonned and Surgeon's Bill and Receipt.

5. Certificates from attendhg Medical Praciitioner / Surgeon flat he patient is fully orred.
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K. M. Layout, Bengaluru, Kamathka 560029,C1N:
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M€mb€r lor 5059449076 . For the latest updated Netwoft hospital list, login to w.medibuddy.in
Empbya cod!: 36338
Rclatlon: Sclf MEDI ASSIST INSURANCE TPA PRIVATE LIMITED.

Oat6 of binh: 2r-S!p-i967 Tower D,4th Floor, IBC Knowledge Pak,4l1, Bannerghatta Road,

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hsFd: K.M.Layout, Bengaluru, lGmataka 560029.C1N:
Primry Vijay Kumar
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Website: !!lll0e!|jug!lyj[ Email: chetan.rao@mediassistindia.coq!

lnlurcr lO: MEMBER2229

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ln the cse oi Dhototess identitv cards isued to beneficiaries. a@ptable proof
of identitu such as Aadhar Card/PassoorUDriver License/ Ration Cdrd / Vdters
lD Card / PAN Card should be preserited at hospitals.
This non-lransferable identifi€tion Grd is valid at selected Network Hospitals
Bsneficiary name: Varshini M & will enable Caid Holder to avail €shless hospitalization only on the basis of
preauthorization by Medi Assist.
Msmber lO: 5076915930 For the latest updated Network hospital list, login to M.medibuddy.in
Employd codo: 36338
MEDI ASSIST INSURANCE TPA PRIVATE LIMITEO.
Ralation: SI ouae

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O.t. of bidh:
Tower D, 4th Floor, IBC lGowledge Pad./.,4l1, Bannerghatta Road,
K. M. Laycut, Bengaluru, Kamathka 560029.C1 N:
Primary lnsurcd: Vijay Kumar
ue51 99KA1 999PTC025676
Valid upto: 22-May-2O22
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