Initial Info to be submitted to Main Office by the Staff regarding Hospitalisation

Sl. No. Name of the Staff

1 Address

2 Name of the District

3 Nature of Illness Detected

Name & Address of the

Hospital and Contract No.
(where the staff Getting
4 Admitted)
5 No. of Beds
6 Hospital Registration No.

7 Name of the Treating Doctor

ed to Main Office by the Staff regarding Hospitalisation

Details
 CHECK LIST FOR SUBMISSION OF CLAIM FOR REIMBURSEMENT WITH CLAIM FORM

Employee Name: - ______________________________Patient Name: - _____________________

Employee No: - ____________________

Member ID No. : - ___________________ Name of the company: -

________________________________

Contact Number: - ___________________ Mobile no. : - ________________________

E- Mail ID: - _____________________

Checklist for Documents:

Claim Form duly signed by you (in Two palces).

►
(Fill the claim amt and Signed Claim Form)

► Original Detailed Discharge summary

(Gives the summary of diagnosis and treatment in hospital, and advice on Dishcarge)

Original Main Hospital bill with Bill Number & break up,
►
(With detailed break up of various heads like Room Rent/OT charges/Nursing Medicines, Lab
charges, OT Consumables etc).

Original Hospital Payment Receipt with receipt number

►
(With seal & signature of hospital) (If main bill does not carry a bill number).

Original Birth Certificate

►
(In Case of Child Birth)

Original Death summary

(Only in case of death of Patient during Hospital stay).

Original Payment Receipt with receipt number

►
(For consultation/surgeon charges if charged outside the main hospital bill).
 Original Pharmacy with Prescriptions and Investigation bills
►
(Along with doctor’s prescriptions & Lab reports, scan (pictures) or X ray films).

Original prescriptions
►
(On doctor’s letterhead mentioning duration and dosage for medicines and advice for
diagnostic tests).

► Investigation reports in original/attested from hospital

(Reports for all tests done along with images)

Police FIR / Medico Legal Certificate (MLC)

►
(Mandatory for All Road traffic accidents-Duly attested by Police and letter from the treating
Doctor stating the details of the injury and H/O alcohol intake at the time of the fall or RTA
( Road Traffic Accidents))

► Gravida Para Living Abortion (GPLA) OR Obstratic History / Ultra Sound (USG)

(Mandatory In case of Maternity claim)