Employee's State Insurance Corporation

EMERGENCY REFERRAL FORM

ESIC Model Hospital : ESIC Model Hospital - Kollam Asramam

Patient Registration
Claim ID. 5146151 Referral No. pvt/1094/23
Date of Admission 01/05/2023 Time: 02:50 Expected Date of 08/05/2023
Discharge

Patient Information
Name of Patient VINCENT J DOB 27/02/1964
Gender Male Relationship with Spouse
Beneficiary
Address BENZYS COTTAGE
CHERUSSERIBHAGAM
CHAVARA P.O.
City KOLLAM State Kerala
Pin Code Country
Mobile No. 8606088439 Telephone No.

Beneficiary Details
UHID No .... Registration No 4810160837
Beneficiary Name MERLIN S Medical Category GEN

Referral Source
Referral Source TRAVANCORE MEDICAL COLLEGE,MEDICITY - KOLLAM
Issue Date 01/05/2023 Reporting Date
Admitting Doctor Ref. Initiating Doctor Dr Preethymol V
Present Complaint ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE
Treatment Recommended
Treatment Procedure
Estimated Duration 8 Days Model Hospital ESIC Model Hospital - Kollam Asramam

Please Indicate Rationale for Referral

ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE

Current Treatment Provider

Treatment Provider
Hospital Name TRAVANCORE MEDICAL COLLEGE,MEDICITY - KOLLAM
Address MYLAPOREL, KOLLAM
MYLAPORE
City KOLLAM State Kerala
Pin Code 691020 Telephone No.

Diagnosis
ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE

Status
Status Approved
ESIC Hospital Comment For Nephrology management.
Hospital Comment

This is to confirm that the patient documents have been scrutinized and his/her ESIC membership has also been established.

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