MDINDIA HEALTHCARE SERVICES(TPA) PVT. LTD.

Branch : ME
Address :
ie
in-G
www.mdindiaonline.com

Email:

CLAIM FORM
NationalInsuranceComPanY I I The New India Assurance ComPanY

OrientallnsuranceGomPanY n The UnitedIndiaInsuranceCompany [-l

1. Current PcilicyNo. :

2. MDIndiaID No. :MD

3. Corporate Name : Employee Code :

4. Name & Address of the Policy Holder :

5. Name of the Patient :

6. Present Contact Address :

7. Contact No. (Resi / Office) : Mobile No. :

g. Have you preferred any claim for the same Insured under the Mediclaim scheme earlier, if so give details
, aiz.
Sr. Particulars Claim 1 Claim 2 Claim 3 Claim 4
No.
(a) Policy Number
(b) Date of Admission
(c) Date of Discharge
(d) Diagnosis
(e) Whether settled / rePudiated
(0 Clairn Amount (if settled) : Rs'

9. Since when the person covered under the policy without break YIS.
Xerox copy of Pievious year's policies MUST be inclosed

10. If the claim is of Domiciliary Hospitalization please indicate

a) Date of Commencement of the treatment

b) Date of ComPletion of treatment

c) Name & Address of attending Medical Practitioner

d) Contact No. Registration No Qualification

 11. Details of Expenses Incurred by the Claimant

SR. DATE BILL NO. PARTICULARS AMOUNT CLAIMED

NO.

GRANDTOTAL
NOTE : Pieaseattach the sheetsif Necessary
In support of the claim, I enclose the iollowing documents
Sr. Particulars Yes/ No Sr. Particulars Yes / No
No. Tick No. Tick
1 Policy Schedule / Policy Copy 8 Prescriptions*
2 Discharge Card / Summary" 9 Pre Hospitalization Medical Bills*
3 Final Hospital Bill* 10 Post Hospitalization Medical Bills*
4 Surgeon s Certificate (In all cases 1l MedicalReports*& MLC / FIR
of surgeryexplaining the procedure) -' (for accidenlcases)
AtienArn;r
odCr.ilIC.i'irit"il1t
5 Speciali.t s/ Anesthetist s bill recerpr
' 12 HospitalPaymentReceipt*
ahd certificateregarding diamosis*
Certif icate from a-"ttendiieNfedical
6 Practihonergiving reasonsfor allowing 13 Indoor CasePaper>(preferablvfor
treatment atlomd* all claims above 1 lakh)
Certificdlefrom attending Medical.
7 Practitioner/ Surgeonthat the patient is Previous Policy Copies, if any
tully cured.'

These documents to be submitted as original.

I have incurred the aboveexpensesfor the heatment of the disease/illness/ accidentand here with as per schedulementionedbelow :

I hereby declarethat the aboveinJormationis true & conect to the best of my knowledge and belief. If I have made any false,fraud or untrue
statement suppressionor concealment,my ght to claim reimbursementof the expensesshall be forfeited.

I alsoconsentand authorize MDINDIA / InsuGnce Company to seekmedical information Irom any Hospital Medical practitionerwho has any
time ;ttended on the insured person.

I herebydeclarethat I have included all bills / receiptsfor purpose o{ this claim and that t will not be making any supplementaryclaim in
' respectthercof,exceptthe post Hospitalization claim if any.

Signature ol Policy Holdet

 MEDICLAIM MEDICAL REPORT (MMR)
CERTIHCATE FROM ATTENDING DOCTOR OF CLAIMANT EROM TI{E NURSIN G HOME / HOSPITAL
1. Name of the patient :

DoB:- /-/- Sex:M f] F n

3. Are you a family doctor of patient ? : Yes / No Since : yrs
4. VVhoreferred the caseto you?

5. When did the patient approach you for the first time in connection with present diseasesuffered ?

Date of First Consultation :

6. Details of previous history of disease/ surgery ( if any ) o{ patient?

7. Is the patient suffering from Diabetes, Hypertension (Blood Pressure),Kidney problems,Cancer,T. 8.,
Heart Problem and AIDS or other disease? If yes (Sincehow long he or she may be suffering from the
same) :

8. Present diseasesuffered ( Diagnosis) :

9. Duration of present diseasesuffered (i.e. since how long he or she may be suffering from present disease
befpre approaching you) :

10 Is the present diseasesuffered connected to previous diseaseof Diabetes, Hypertension (Blood Pressure),
Surgery or other existing disease ? _

11. Is diseasesuffered Acute or Chronic ?

12. \A/hetherthe diseaseis caused due to any congenital defects (Yes / No) ?

13. \t\rheiherthe patient had any complications during or after pregnancy (Yes / No) ?

14. V\ihetherthe disease/ injury is caused directly or indirectly due to the use of alcohol or drugs
( Y e s / N o ): _

15. Could the patient have been aware the illness or diseaseof which keatment is being taken now ?

If yes when? (Approx. Period of illness) :

Date when the illness / iniury was sustained :

 a

16.Is the diseasesufferedrequireshospitalization? Yes/ No

a) Nature of treatment given : -Operative/ I. V. Fluid / Injection / Oral Treatment / Othef Pareilteral
Treatment

, b) Indoor caseno. of the patient Hospital / Nursing home :

17. Date of Admission : Time of Admission :

18. Date of Discharge : Time of discharge :

19. Is your hospital registered with local authority? If yes, please attach xerox copy of certificate
Regiskation Number of Hospital :

20..No. o{ total bedsin your Nursing Home / Hospital :

21. Qther commentsyou would like to make (iI any) connectedto present diseasesuffered by the
Patient :

22."IAftether the patient is fully cured or not ?" Yes / No

,
.l Ce*ified that the details furnished above are true to the best of my knowledge and as per the records
available at this hospital.

Doctor's Name : Qualification : RegistrationNo.:

Contact No.:

Signature of Attending Doctor

(With rubber stamp and registration no. o{ your Nursing Home / Hospital )

Name of Poliry Holder :

Signatureof PolicYHolder