Scribd Logo
Upload

Welcome to Scribd!

  • 679 views

    GHPL Claim Form

    Uploaded by

    adddata
    This document is a hospitalization claim form for Good Health Plan Limited. It requests information about the patient, including name, age, policy details, illness or injury details like diagnosis, treatment details, dates of admission and discharge, treating doctor details. It also requests bank account details of the policy holder for claim reimbursement. The treatment costs are listed along with amounts charged, discounts, net amount, patient paid amount and balance due. Undertaking is given by patient for truth of information. Checklist of required documents like bills, reports, receipts is provided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    GHPL Claim Form

    Uploaded by

    adddata
    679 views2 pages
    This document is a hospitalization claim form for Good Health Plan Limited. It requests information about the patient, including name, age, policy details, illness or injury details like diagnosis, treatment details, dates of admission and discharge, treating doctor details. It also requests bank account details of the policy holder for claim reimbursement. The treatment costs are listed along with amounts charged, discounts, net amount, patient paid amount and balance due. Undertaking is given by patient for truth of information. Checklist of required documents like bills, reports, receipts is provided.

    Original Description:

    vvfgfgfgfgf

    Original Title

    Ghpl Claim Form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a hospitalization claim form for Good Health Plan Limited. It requests information about the patient, including name, age, policy details, illness or injury details like diagnosis, treatment details, dates of admission and discharge, treating doctor details. It also requests bank account details of the policy holder for claim reimbursement. The treatment costs are listed along with amounts charged, discounts, net amount, patient paid amount and balance due. Undertaking is given by patient for truth of information. Checklist of required documents like bills, reports, receipts is provided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    679 views2 pages

    GHPL Claim Form

    Uploaded by

    adddata
    This document is a hospitalization claim form for Good Health Plan Limited. It requests information about the patient, including name, age, policy details, illness or injury details like diagnosis, treatment details, dates of admission and discharge, treating doctor details. It also requests bank account details of the policy holder for claim reimbursement. The treatment costs are listed along with amounts charged, discounts, net amount, patient paid amount and balance due. Undertaking is given by patient for truth of information. Checklist of required documents like bills, reports, receipts is provided.

    Copyright:

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

    Good Health Plan Limited

    Plot no-49,Nagarjuna Hills


    Hyderabad-500082
    Phone: 1860 4253232
    Fax: 1860 4254242
    WITHOUT PREJUDICE
    HOSPITALISATION CLAIM FORM
    Issuance of this form does not amount to admission of any liability under the claim on the part of the insurers

    Patient Information
    Card ID
    Name
    Age
    Relationship to Insured
    Contact no
    E Mail Id
    Member covered since
    Hospital / Provider name
    Provider code

    Policy Holder Information


    Name
    Address
    Insurer
    Policy No

    Information on Illness / Injury and Treatment


    Ailment / injury for whichthe member was treated
    Date of admission
    Date of discharge
    Principal Diagnosis
    Other Diagnosis
    Medico legal
    Yes/No

    To

    Time of admission
    Time of discharge

    AM/PM
    AM/PM

    Road Accident

    Yes/No

    First occurrence (Patient known


    to have this condition since)

    Disease code (1C0)


    Line of Treatment (Procedure done)
    Procedure code (CPT)
    Treating doctor details

    Period

    Name:
    Qualification:
    Phone no:
    Reg no:

    Bank Account Details - This information is mandatory for customers of United India Insurance Co. Ltd

    Name of Account Holder


    Mobile number
    IFSC Code
    Bank name

    Account Type (Savings/Current)

    Full Bank Account number(Without /,- or any


    special characters)

    Bank Address
    Note 1- The Account should be in name of Employee / Main Member
    Note 2-Please attach a photocopy of cancelled cheque leaf relating to this account
    Page 1 of 2

    Treatment cost
    S.No

    Service Description

    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11

    Room Charges
    ICU/IICU/Nursery charges
    Doctor's Fee
    Lab Investigation
    Radiology
    Other Investigation
    Special Procedure
    Pharmacy Service
    OT/ Labour Room Service
    Others (PI specify)
    Total amount claimed

    Amount Disco
    Net
    Charged unt Amount

    Patient Paid
    Amount

    Balance
    Due

    Remarks

    UNDERTAKING BY THE PATIENT:


    I hereby warrant the truth of the foregoing particulars in every respect& I agree that if I have made or
    shall make any false or untrue statement, suppression or concealmentmy right to claimreimbursement of
    the expenses shall be absolutely forfeited.
    I also authorize the hospital/provider to submit the attested Indoor Case Papers (Case sheets) and any
    other documentsOr information related to my treatment to GHPL if asked for.
    I further declare that in respect of the above treatment no benefits are admissible under any other
    Medical Scheme or Insurance.
    I here by confirm that I am making no other insurance claim for the event claimed by me under this policy.

    Provider Representative
    Name:
    Date:
    Signature _____________________
    Check list of documents
    Consolidated final hospitalization bill with
    cash paid receipt (stamped) in original
    Break up of hospitalization bill (Detailed bill)
    in original
    If Surgery is involved, Surgery bills / OT
    receipt in original
    Pharmacy Bills with prescriptions in original
    Discharge Summary in original
    Investigation Reports in original

    Policy Holder/Patient
    Name:
    Date:
    Signature ________________

    Consultation bills with Receipt in


    original
    Pre authorisation / First Admission
    Report in original
    Copy of photo identity of the patient
    (if patient is a dependent) and the
    insured
    Service employee
    line Information
    Other bills, receipts and reports in
    original
    Comments/Remarks
    Photo Copy of a cancelled cheque leaf
    Page 2 of 2

    You might also like