ee RY Paramo unt Health Sei eA nn ut Services & Insurance TPA Prt. Lid CLAIM FORM - PART A een ash, RDA License No So SO ee eae (Tobe Sled i block leters) The eof his Frm sot be ken aa dieing DI TAILS OF PRIMARY INSURED, 8) Policy No: Bik olla ee = =a Ost Ne coimeee Colle Ile SIOIOIOILLAOOAIAIA a] ifcte No: ou a lo: Cl 1 ¢) Pi(fio/ TPA 1D No: [3 [9 JLo JL. 4 + CMMI eae ela RIT ©) Address : 2 MOMMA SEs (SI [om J { IE I CI 2 ae aera soc FI MAIO ale Pincode: [] 212 ILollolz) z DETAILS OF INSURANCE HISTORY: 12) Curent covered by ay other Medica Healt mmce Ye Oo tg 'b) Date of commencement of first Insurance without break: (D ][D ] [Mt ][M] [YJ |(Copies of Policies to be attached) = ©) If yes, company name: | Policy No.[_]] a Sum Insured (Rs) 4) Have you bee bape inthe st 4 years? Yes NO io Date: [M ][M] [Ly JLY J Diagnosis: ce ¢) Previously covered by any other Mediclaim / Health insurance : Yes [No ‘)Ifyes, Company Name ] Oo DETAILS OF INSURED PERSON HOSPITALIZED anime PIAS IMs eel a ele) tyGende: CMale FFenalec) Age: yean[] |[&] montsLO opueorsims [6)G) THB ¢) Relationship to Primary insured: SN7Spouse F Child Father Mother Other T~ (Please Speci) ‘Occupation: Sevist7“SefEnployed Homemaker Suéent” Reid oer (Penespci| Bs Adds diferent om above) yo sate Pin Code Phone No: a |I nc | celta vine eS WORD paral ) +b) Room Category occupied: Ie no «) Hospitalization due to: tacmy to: Ijury F Tness oPucet Adnision PIE) [SIDR] IIE tim: (BIT Gost 4 Date of nju ptm (97) (3) ‘Injury give cause: Seif intited Road Tac Accident” Substance Abuse | Ani ComsP Fad 7 YAP No_j)Sytemof Mdin: ii, Reported to police: F Yeu T Noi, MLC Report & Police FIR ats DETAILS OF CLAIM. Ls Deak te tent aprons cetoet Tet fame = m aye | Hospi Daily Cost} 1 | Pehosiatiaton enon 4 | Mapiataton apes Post-bspializaton expenses ie | Heatw-cocck wp Cot vy | _Ambutasee Charges Oven oto IL] El) 3 ormmre beds per ary Date Disease int eet IDte of Delivery aan ied no Oe Gel pra coewe (I) CGA FS) gon 7. 1f Medico legal: F Ye No [cin pocomcne Sabet Cock Ut IF Chaim Form Duly sone Copy of tec nimation Hospital Main Bill Hospital Break-up Bil Hospital Bill Pyent Recipt Hospital Discharge Summary val [pc hopiatinion pane Des (_I_IL_] [Poot Dom [JEL cit mnt atte Fes no tre provide eta nmer®) aypunkNane [E7 DRC Gank I ) Cheque / DD Payable details: DACLARATION BY THE INSURED DETAlls OF LL ENCLOSED se a ily ie 1 aol] pine en 2 ofolmlal le manana pu CCH 2S 4A) toiyn 3 of ofm™| mf y|y |Postnosptalzation Bilt: NOs 1 4 . ul ul] y|y | Health-Cneck Up Cost [ 5 D ul vy [ambulance Charges [ a AMMELIC a 3 7 3 v[¥ r= ! @ poll [ey le ° ololm||«]y Team. : 10 opolale| y|y ea $ roa LSAT e pax: [CGID IP IOS ISIE NE Im)» AsomtNumes THe ln Jeltolla sy als Wssls Je I o o1rsc cose: of anonS71) Hi g 5 : ‘ tmnt [Yelakanka Trewhy erie ha be lomaton fasbedi is nmi ue 8 caret ihe et of my debe do crwet nore TPA Faure compa ‘Sevanden tm paren ep a Seperation Sony owe Tole) Cole) roi kre an yin re ter pee fae ee cea one Ss aa Pacoe e a re oad asetit mega ence aca ana a marge Sa ‘Signature of the Insured we zCLAIM FORM, Ee PART ‘TO BE FILLED IN BY THE HOSPITAL The isu ofthis Form i not ibe ake sn ison of (To be ftled in black tet Tabi Plee ict the xg pestborizson request Tam nino PART A DETAILS OF HOSPITAL, 2) Name ofthe spt rn Bari ee HIDE ea Ee ea te DbIwIaIZIO ] aod Tyco: Newa Nen Network Poon ‘network fil section BE) 2 eles ale Type JL mIOOOoooOoooooo J =a CAI IIIT) Prone no. [I COO MC) Goug ees Vv Cig UIA Ie [I 1) Registration Number] SIS JILL JR 16.19) Gender: Mate arle 7 0) Ape: Yeu ven: To] EIS I )Dateof Admission TOT) Dol DEE] atm: IEE): (Q IR) © Dae ottiscares: Te [2 RT: L Type ofAdminsion: Emergency Matesity © Paned Day Car 7 i) IfMatemity i,Date of Dever: [OLD Suu Suns tinct diame: Discharge toboret’~Discrge to snot hospital F Deceased DETAILS OF AILMENT DIAGNOSED (PRIMARY) = > 16D 10 Cnt Devine > Ton ee $ Trim | =} ie Dios: | | ‘Ladin i Om : | medicine | 2 ol paul 7 a = ©) Pre-auorizaton obtained: Fra Nyy SB Pr Naurber = v = eet ia MN z ¢) I authorization by network hospital na bined, give reason: [_ s {) Hospitalization duc to Injury: Yes No ilfYes,givecause Self Road Traffic Accident I” Substance abuse / alcohol consumption 7 = Ii. IF Injury due to Substance abuse sleabol consumption, Tet Condujaexablsh his a FYeu No (ies, attach reports) i, Medio egal: Yeu J7o. v. Reported io Police: Pes No ¥-FIR 0 Yes pest dein BET a | (CLAIM DOCUMENTS SUBMITTED - CHECK List TF Chaim own duly signed IF invesigationepors Original Pre-autorzation request IF CTIMRIUSGIHPE investigation reports Copy of the Pre-authorization approval letter I Doctor's reference slip for investigation Copy of photo ID card of patient verified by hospital Ir BCG Hospital Discharge summary IF Pharmacy bls Operation Theatre notes | MLC report & Police FIR Hospital main bill IT Original death summary from hospital where applicable Hospital break-up bill IT Any other, please specify— a SSS ASE OF NON NETWORK Hosea ont eats ress of the Hospital ‘Ge ] De a BE NON-NETWORK HOSPITAL) — | 2 eee eae tie | peSSeeSsooSesss5) ial OOSS8eS [ma ow a sae (Cal AGE SEG] = orrecisteation No. Jo) Number of Tapationt bods [{][C ][O]} 9 Facilites availabe in the hospital (PLEASE READ VERY CAREFULLY) ___{Rereby declare thatthe inlrmation forished in this claim frm is wue & correct oto best of my mnowedge and bela. have made any false or unirve ___Rtalement, suppression or conceaiment of any mater fac, my right to aim reimbursement shal bo foro | also consent & auhorize TPA insurance ‘Company, i Seek necessary medical information| documents from any hospital | Medical Pracitoner who has aliended on the person against whom ths cai is made | hereby dociare that have included all the bls | receipts forthe purpose of is caim & that wil nol ba making any supplementary claim except the Prelposthosptaztion csi, any dee: [o lL) Dolls) 218 ree Gaza | Siguatuc ofthe Isured | [7- f DECLARATION BY THE HOSPITAL: \We hereby declare thatthe information furnished inthis Claim Form is tue & corect ot best of our knowledge and bell. fwe have made any false or untrue statement, 3n or concealment of any material fac.our right to claim undor bis claim shal be forfeited. The stature ofthe insured is taken Bie suppress Con this form aiter Claim Form B is fully filed up by us Due: [OS] PONE (OIE) race: (Roatan DECLARATION BY THE INSURED (PLEASE READ VERY CAREFULLY)Provisional registration No‘0608600783 Goenentl is GOVERNMENT OF HARYANA District Registering Authority GURGAON CERTIFICATE OF PROVISIONAL REGISTRATION ‘This s to cerily that PK HEALTHCARE PRIVATE LIMITED located at SECTOR-53 GOLF COURSE ROAD GURUGRAM owned by DR SANJAY DURANThas been granted provisional registration as a clinical establishment under Section 15 of The Cinical Establishments (Registration and Regulation) Act, 2010. The Clinical Establishment is registered for providing medical services as a Hospital, Polyelinie Physiotherapy, Dental (Clinic Dialysis Day Care Ceatre, OPTHALMOLOGY, BLOOD BANK, ‘Pathology, #lsematology Biochemistry Microbiology, Xray Centre, ECG Centre. MRI CeatreUltraSound Centre,CTScan (Centre under Allophathy System of Medicine. DRA: Gurgaon Designation’ [ssuing Authority District jal Officer Clinics" Eoiaol ;nment Act (CEA) Gurugram ‘This Certificate is valid for 8 period of one year from the date of issue. Place: Gurgaon Date of Issue: 08/09/2022 1. The holder ofthis Certificate of Registration shall comply wit al the provisions of Clinical Establishment Act (Registration and Regulation) 2010 and the Rules made there under. 2. The Cerificate of Registration is not transferable, The Certfcate of Registration shal be displayed in a ‘prominent place in a part of the premises open tothe publi, 3. Any change of ownership or change of category oF change of management or on ceasing to function as a clinical establishment, the certificate of registration shal be surendered tothe authority and application for fresh registration submitted. senna yr tharos DRAM ral ep SRF ONDE HOH seNENIBRN Oo UNE