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  • Annexure1 2320194 14-06-2023

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    SDH HALVAD
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    This document contains beneficiary and hospital claim details from a health insurance transaction management system. It lists the beneficiary ID and name, hospital name and location, referral details, admission date and time, and discharge date. The document also includes a claim details table with package codes, treatment descriptions, and the claimed amount versus approved package amount. It is certified by the competent hospital authority that the claim is genuine and has not been previously submitted.

    Original Description:

    ANNEXER 1

    Original Title

    Annexure1_2320194_14-06-2023

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    This document contains beneficiary and hospital claim details from a health insurance transaction management system. It lists the beneficiary ID and name, hospital name and location, referral details, admission date and time, and discharge date. The document also includes a claim details table with package codes, treatment descriptions, and the claimed amount versus approved package amount. It is certified by the competent hospital authority that the claim is genuine and has not been previously submitted.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    10 views2 pages

    Annexure1 2320194 14-06-2023

    Uploaded by

    SDH HALVAD
    This document contains beneficiary and hospital claim details from a health insurance transaction management system. It lists the beneficiary ID and name, hospital name and location, referral details, admission date and time, and discharge date. The document also includes a claim details table with package codes, treatment descriptions, and the claimed amount versus approved package amount. It is certified by the competent hospital authority that the claim is genuine and has not been previously submitted.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 2

    Beneficiary wise claim details

    1. Beneficiary ID:

    2. Beneficiary Name:

    3. Hospital Name:

    4. Hospital Region/City: null , null

    5. Referral ID:

    6. Date of Referral:

    7. Date and time of admission/consultation/investigation:

    8. Date and time of discharge: NA

    9. Case ID:
    Claim details as available in the Transaction Management System(TMS) module:

    (Rs. in actuals)

    Sr.No. Referral/Emergency Package Code Package name/ OPD/IPD Amount of the Amount claimed by
    /Planned Treatment/ package hospital
    Investigation details

    1.

    It is certified that the claim is genuine.No such payment has ever been claimed and the same claim will not be submitted in future.

    Competent Authority of the Hospital


    Dr. Harshita G. Patel MEDCO

    This document is generated and verified by an Aadhaar authenticated user

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