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OOOOOooo0oo ETAMLS OF THE PATIENT ADMITTED dederee COBO SOOSOOCOOEoeeoOseeeoOoOsoeEosoessso wp resisrsion ster IO OOOO acwnie sate rama optge Yew IE] monn a] sinaeetven: IE] CA] toi EI GO HO ome WO : BO OO im GO BO paren] ome my] BO OM twee OOO Sanus ane ct decree Dachage to home [Dicere te arer hoe) oacanad stata moe OOOOOOO DETAILS OF AILMENT DIAGNOSED (PRIMARY) eine oiemis LL ILL Pst UUUWWUU rear eee FIONN ‘rsmtoe 2 goo0o00000 icon — TIMIMANNNN areas FIOMANNN veces LILI wo ot Prva remeron searee Dre One geratewer wee § $OOOODDO0O00000 efeitos method crane gers [ 1 c fs sts se and emi, whe Yom ne Yen ate apa stn Cle TI 2 mteresopae Ce Ose CC rosetanen se sun: Cree ne ree siecuse srt CJ ne rte ce CD bs he CT cmnten stat a Ton rests q este cre rennin ns cayman no 5 Ltn ores sry 5 mer omar nue secre extant =) than sk ey a ‘ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILLIN CASE OF NON-NETWORK HOSPITAL) sweetest TO OOODDOODOOOOOOOoO0oO00000000u! CREE coer Co Eee eo eoE EE moss CICIIOLIO ~ sine 00 twmene ce OOOOSOoO emote QODOOGOOOG sarc COQ sim eoniaes ce Sw Coe ver Cree DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY) SESE SL LN a SE TF ron ue gana i | 1. 9CONSENT FORM FOR VERIFICATION & COLLECTION OF IPD PAPERS To Dated: (Hospital Name) (Address) Dear Sir / Madam, SUBJECT: CONSENT FORM FOR VERIFICATION & COLLECTION OF IPD PAPERS Thereby authorize the representative of Vidal Health Insurance TPA Pvt. Ltd. to verify & collect photocopy of all of my IPD papers related to following hospitalization :- Name of the Patient- Hospital UHID No- Date of Admissio Date of Discharge Diagnosis as per Discharge Card Self attested photo id proof of Patient/ Guardian (if patient is minor) is attached Thanking you. Yours truly, (Signature of the Patient / Guardian (if the patient is minor))Policy Holder's Details = Name : Address : Contact No Policy No Vipul Card No :. (Signature of the Insured)LIST OF DOCUMENTS REQUIRED FOR SETTLEMENT OF HOSPITALISATION CLAIMS FORCLAIMING HOSPITALISATION EXPENSES: CLAIMFORM- PART A: DULY COMPLETED BY THE INSURED ON THE PRESCRIBED FORMAT -ORIGINAL (CLAIMFORM— PART B: DULY COMPLETED AND SIGNED BY THE HOSPITAL AUTHORITIES - ORIGINAL ‘ADNISSIONNOTES- CERTIFIED COPY "TPA ID CARD XEROXCOPY “ANY OTHER TD PROOF LIKE VOTER ID) OL PASSPORT ETG-COPY ‘ADDRESS PROOF -COPY REFERRALLETTER, IFANY, TOHOSPITAL - CERTIFIED COPY 2) of a) m] of ole|> DETAILED DISCHARGE SUMMARY- ORIGINAL DEATH SUNMARY (NSTEAD OF Discharge Surimary|IF PATIENT HAS PASSED AWAY DURING HOSPITALISATION = ORIGINAL INVESTIGATION REPORTS -IN ORIGINAL - FOR INVESTIGATIONS DONE DURING HOSPITALIZATION SUPPORTED BY FILM CDS, IF ANY HISTOPATHOLOGY REPORT, IF ANY, INORIGINAL (CERTIFIED COPY OF OPERATION THEATRE (OT) NOTES - WHERE SURGERY IS PERFORNED TILE REPORT/FIR FOR ACCIDENT CASES CERTIFIED COPY ‘STICKERFORTHE IMPLANTSUSED- ORIGINAL ‘SUPPORTING INVOICE FOR THE IMPLANTS USED - CERTIFIED COPY OSPITALMAINBILL - ORIGINAL ‘BREAK-UP BILL FOR THE HOSPITAL MAI BILL- ORIGINAL DDETAILEDEILL FOR THE NON -ADMISSIBLE AMOUNTS COLLECTED FROMTHE PATIENT RECEIPT FOR THE AMOUNT COLLECTED FROM THE PATIENT MATERNITY CLAIN- GPLASTATUS "ANY OTHER DOCUMENT THAT THE CLAIM PROCESSING TEAM TPA REQUESTS: PRESCRIPTIONS FOR WEDIGINES PURCHASED DURING HOSPITALISATION =| <}¢) 4] a] a of a] 0 2 =| -| 2 ‘COPY OF VALIDILATEST HOSPITAL REGISTRATION CERTIFICATEIN CASE OF NON-NETWORK HOSPITAL ANDIOR (COPY OF BIO MEDICAL WASTE CERTIFICATE COPY SPECIFYING THE NO OF INPATIENT BEDSIN HOSPITAL, TISTOF BILLS SUBNITTEDWITH THE AMOUNT UNDER EACHEILL (DOCUMENTS FOR NATIONAL ELECTRONIC FUND TRANSFER (NEFT) ORIGINAL COLOURED CANCEL CHEQUE WITH AIC HOLDER NAME IF CANCELLED CHEQUE DOES NOT PRINTED PROPOSER NAME THEN REGURED PASSBOOK COPY WITH [ATTESTED FROM SANK OR BANK STATEMENT WITH FULLY MENTIONED ACCOUNT HOLDER NAME, IFSC CODE, & ‘ACCOUNT NO. Zz ‘COVERING LETTER STATING YOUR COMPLETE CURRENT ADDRESS, CONTAGT NUMBER AND THE LIST OF DOCUMENTS ATTACHED. ia TPA RESERVES TO RIGHT TO REQUEST FOR ANY ADDITIONAL MEDICAL DOCUMENTS TO DETERMINE ELIGIBILITY OF HE CLAIM, PLEASE KEEP ONE SET OF PHOTOCOPY OF ALL THE DOCUMENTS SUBWITTED FOR REIMBURSEMENT. | 2: FOR CLAIMING PRE-HOSPITALISATION EXPENSES a CATR FOR PRT DUEY- COMPLETED ARDS ISHED $$$ $+ ‘COPD CONSULTATION PAPER. PANY =ORIGINAL PRESCRIPTION FOR MEDICINES PURCHASED PRIOR TO HOSPITALSSATION Page]__[ DOCUMENTS FOR NATIONAL ELECTRONIC FUND TRANSFER (NEFT) AS INITEM |- 7’ ABOVE. TL SORERING CErTER’STATING YOUR COMPLETE CURRENT RUDRESS, CONTACT NUMBER & UST OF DOCUMENT TH HED ‘3. FOR CLAIMING POST-HOSPITALISATION EXPENSES CLAIMFORM- PART A DULY COMPLETED AND SIGNED ‘OPD CONSULTATION PAPER, IF ANY -ORIGINAL ‘CONSULTATIONBILL/ CASH RECEIPT. IF ANY. PRESCRIPTION FOR MEDICINES PURCHASED. POST-DISCHARGE, INVESTIGATION REPORTS - IN ORIGINAL — FOR INVESTIGATIONS DONE. POST-DISGHARGE,IFANY CCASHBILLS FOR THE INVESTIGATIONS DONE- POST-DISCHARGE REFERENCE LETTER FOR INVESTIGATION CONDUCTED. POST-DISGHARGE b c rl '@ | PHARMACY BILLS FORMEDICINES PURCHASED - POST DISCHARGE f 9 fr i DOCUMENTS FOR NATIONAL ELECTRONIC FUND TRANSFER (NEFT)AS INITEM 1-2 ABOVE WERING LETTER STATING YOUR COWPLETE CURRENT ADDRESS CONTACT NUMBER AND THELIST OF] J | BOGUMENTS ATTACHED Note: TPA reserves the right to request for any addtional medical documents to determine eligibilly ofthe claim, keep one set of photocopy ofall the documents submitted for reimbursement