16CB01OIC0628

-Z
SevenHills
Ce
HOSPITAL
IN PATIENT - CREDIT FINAL BILL

To
V1PUL MEDCORP TPA,
V1PUL MEDCORP PVT. LTD. CLAIMS DEPARTMENT B14.
WADALA UDYOG BHAVAN, WADALA (W), MUMBAI-400031
MUMBALMAHARASHTRA
INDIA-400 031
Patient Name: ANANYA MOOKHERJEE
Bill No:
BIPR1506010006
Bill Date:
01/06/2015 11:47
UHID:
MCH2400076
Patient No:
1150527006
Bed No:
6118
111111111111111111111111111111111111111
111111111111111111111111111111111
Pay Type:
CREDIT
Age(Sex): 30Y 5M (F)
Bill Type:
NORMAL
Sponsor: VIPUL MEDCORP TPA
Dr Name
DR.CHITWAN DUBEY
Employee No:
Relation With Patient:
Emp Name:
Ref.Lr.No -- Date:

Discharge Date:
01/06/2015 11:45
Jmission Date: 27/05/2015 05:01

Amount(Rs.) Sr No
Sr No Payments
1 PAYMENT AND
41,379.00
Account Heads
DOCTOR CONSULTATION
MISCELLANEOUS GENERAL
REGISTRATION
PROCEDURES
Total Amount (Rs.)
LAB CHARGES
ROOM RENT
Emp1O`Jec
Net Amount (Rs.)
6,550.00
6,550.00
170.00
170.00
240.00
240.00
8,940.00
8,940.00
680.00
680.00
3,000.00
3,000.00
PHARMACY
4,294.39
4,294.39
PACKAGES
66,000.00
66,000.00
DIET
1,505.00
1,505.00
frawL
,
Sigcet'
pate ------
4t6huiet
Ninety-One Thousand Three Hundred Seventy-Nine And Thirty-Nine Poise
only
Billed Amount(Rs):(+)
91,379.39
Collected Amount(Rs):(-)
41,379.00
Total Amount(Rs):
50,000.39
Round Amount(Rs):
-0.39
Net Payable(Fis):
50,000.00
Rupees:
Net Payable In Words: (Rupees)Fifty Thousand only
For SEVENH
,frovi
LTH CARE PVT LTD, Verified the above a rid found correct
Checked By:
Prepared By:
L:
Autho
Attendant/Patient Signature
NOTE:
I. Any correspondence ojtis bill should only be addressed to the Director, SEVENHILLS HEALTH CARE PVT LTD,MUMBAI.
2. The Cheque/OD shoul&be issued in favour of SEVENHILLS HEALTH CARE PVT LTD,MUMBAI. Our PAN No. is:
3. The disputes on this bills, if any shall be under the jurisdiction of MUMBAI only.
4. Acknowledgements/Signatures are as per the individual / seperate bills enclosed here with bearing page no. from to
SevenHills HealthCity

Caen.
.401.
Onki et.igra
Marol Maroshi Road, Andheri (East), Mumbal - 400 059.

Ph.: 022-6767 6767 www.sevenhillshospital.com
tatAMENTIMS
HOSPITAL
UHID No
: MCH2400076
Patient Name
:ANANYA MOOKHERJEE
Age ( Sex )
:30Y ( Female )

:27/05/2015 05:01
Discharge On
:01/06/2015

:6118 (L6 B8 SINGLE ROOMS)
Discharge Type :NORMAL
: VIPUL MEDCORP
Admission Date
Bed No
Sponsor
Clinical Dept
UP No
:1150527006
: OBSTETRICS I GYNAECOLOGY
DIAGNOSIS : SUPERVISION OF NORMAL PREGNANCY - Z34

PRIMI WITH 39.2 WK WITH LP WITH HYPOTHYROIDISM WITH IMPAIRED GTT FIBROID'
UTERUS
CONSULTANT
DR.CHITVVAN DUBEY'
REASON FOR ADMISSION (Salient History
presenting complaints)
DIAGNOSIS-30 YR OLD ML 2 AND 1/2 YR SPONTANIOUSLY CONCEIVED PRIMIGRAVIDA WITH
39.2 WKS WITH LABOUR PAINS WITH HYPOTHYROIDISM WITH IMPAIRED GTT
CHIEF COMPLAIN- H/0 AMENORRHOEA SINCE 9 MONTH
C/O PAIN ABDOMEN SINCE 2 HR
PRESENT ILLNESS- PARIENT IS ADMITTED WITH C/O PAIN IN ABDOMEN AND BLEEDING PV
SINCE 1-2 HR FOLLLO WING AMENORRHOEA OF 9 MONTHS. PATIENT HAS C/O PAIN
ABDOMEN RAIATING FROM BACK TO THIGHS. SHE ALSO HAS C/O BLEEDING PV. THERE IS
NO C/O LPV AND DECREASE FETAL MOVEMENT.
REGISTERED,TT IMMUNISED,REGULAR CHECK UP
H/0 FLUVIR PROPHYLAXIS AT 30 WK
M/HLMP-25-08-2015
EDD-01-06-2015
PREVIOUS MENSTRUAL CYCLE-3-4DAY/30 DAYS/AVG BLEEDING
0/H ML-2 AND 1/2 YR
PRIMIGRAVIDA
P/H-MEDICAL ILLNESS-H/0 HYPOTHYROIDISM
SURICA ILLNESS- NO SIGNIFICANT HISTORY
TREATMENT HISTORY-ON THYRONORM 12.5 MCG
F/H-NO SIGNIFICANT HISTORY
PERSONNEL HISTORY-ADDICTION- NONE
CONTRACEPTIVE METHOD-NONE
BLADDER AND BOWEL HABIT-NORMAL
NflL
beemiell.ne
Marol Maroshi Road, Andheri (East), Mumbai - 400 059.

re. 7
UHID No
Patient Name
yen11))
r
: MCH2400075ft
:ANANYA M
: 1150527006
:30Y ( Female )
A Li
EXAMINATION FINDINGS (Salient genPal and gyeemic exam results)*
0/ECONCIOUS ORIENTED
T-AFEB
P-76/M
BP-120/70MMHG
RR-20/M
PALLOR-ABS
OEDEMA-ABS
ICTERUS-ABS
CVS-S1S2 PRESENT NO MURMUR
RESP-B/L E AIR ENTRY NO CREPS AND RONCHI
P/AFULL TERM
VERTEX
HEAD-5/5
LOA
FHR-146/M REGULAR
UTERUS IRRITABLE
P/S-NO LEAKING NO BLEEDING
PN-CERVICAL OS CLOSED,CEVIX UNEFFACED, POSTERIOR, SHOW PRESENT
HEAD STATION AT -3,PELVIS ADEQUATE
COURSE OF MANAGEMENT (Salient Medications, Surgery performed, Complications, if any, during
marIPMEEPLAKEVIVACUUM ASSISTED VAGINAL DELIVERY WITH MEDIOLATERAL EPISIOTOMY ON
28/05/15
FEMALE BABY, WT- 3.175 KG ON 28/05/15 AT 10:45AM
PT IN LITHOTMY POSITION. BLADDER EMPTIED
WITH GOOD UTERINE CONTRACTIONS AND FULL DILATATION OF CERVIX PT ASKED TO
BEAR DOWN
VACUUM APPLIED IN/0 POOR MATERNAL BEARING DOWN EFFORTS
BABY DELIVERED BY VX, CRIED IMMEDIATELY AFTER BIRTH
CORD CLAMPED AND CUT AND BABY HANDED OVER TO NEONATOLOGIST
PLACENTA AND MEMBRANES DELIVERED OUT COMPLETELY
UT WELL CONTRACTED, NO E/O TEAR
CERVIX EXPLORED,NO E/O TEAR
EPISIOTIMY SUTURED IN LAYERS WITH 2-0 VICRYL
PT WITHSTOOD PROCEDURE WELL
SIGNIFICANT INVESTIGATIONS DURING STAY
WITH PATIENT
PATIENTS CONDITION AT THE TIME OF DISCHARGE (Brief notes on clinical condition
GC- FAIR
PR-80/M
BP-110/70MMHG
CHEST-B/L CLEAR
CVS-S1S2 NORMAL
P/A- SOFT
Pogo 2 of 4

Oira,0 Kalil
031471*
1.211141111.
L-Z
SevenHills
HOSPITAL

UHIO No
MCH2400076

Patient Name
:ANANYA MOOKHERJEE
IP No :1150527006

Age ( Sex )
:30Y ( Female )
LIE- LOCHIA HEALTHY

EPI HEALTHY
PASSED URINE
PASSED MOTION
MANAGEMENT PLAN ON DISCHARGE "
ON ORAL MEDICATION
DISCHARGE MEDICATIONS (advice on medication till next review)"
T CEFTUM 500 MG 1BD
T RANTAC 150 MG 1BD
T COMBIFLAM 1BD
T CHYMORAL FORTE 1BD
STP CREMAFFIN 30 ML SOS
ALL MEDICATION FOR 5 DAYS
FOOD & DRUG INTERACTIONS "
1.Anti-histaminics- alcohol to be avoided
2.Analgesics/Antipyretics- take along with food. Avoid alcohol
3.NSAIDs- To be taken with food or milk. Avoid alcohol
4.Narcotic Analgesics-alcohol to be avoided
5.Bronchodilators- avoid foods and drinks that have caffeine. Avoid alcohol
6.Anticoagulants- take on empty stomach. Avoid cranberry juices/products % alcohol.
7.Diuretics- to be taken with food, avoid potassium rich foods.
8.Statins- to be taken with evening meal. Avoid alcohol
9.Beta blockers- take with meal or right after meal,
10.ACE Inhibitors- take one hour before meals, avoid potassium rich foods.
FOLLOW-UP INSTRUCTIONS *
F/U AFTER 10 DAYS WITH PRIOR APPOINTMENT
ALLERGY"
NO ANY ALLERGIC REACTION FOUND TO ANY DRUGS
CONTACT NUMBER IN CASE OF EMERGENCY
1 .PAIN
2.BLEEDING
3.FEVER
4.
In case of above complaints, please seek emergency attention. Please contaaloriftimediate
*
assistance.
SevenHills Hospital - CM0 (Emergency Dept) Ph: 022 - 67676767 (Ext 71583, 71554)h
Page 3 of 4

N L
Oseell
0t714
11.11,144119

UHID No : MCH24000
Patient Name :ANANYA
:1150527006
:30Y( Female)
ma) Mire
I T A L
0 S
n 1111
Age ( Sex )
"
.12_10
DR. PREETI
Authorized On: 32115/2015 14:31
End of Discharge Summary
Page 4 of 4

NAOIL
Com..
eniMmilem
Marol Maroshi Road, Andheri (East), Mumbal - 400 059. Ph.: 022-6767 6767 www.sevenhillshospital.com
HOC
SevenHills
HOSPITAL
Covering Letter
No:SHH/AcctNIPUL MEDCORP TPA

01/06/2015
Date:
To
Vipul Medcorp Pvt. Ltd. Claims Department B14.
Wadala Udyog Bhavan, Wadala (W), Mumbai-400031
MUMBAI,MAHARASHTRA
INDIA-400 031
Ph No:9833353064
Dear Sir,
Sub: Medical Treatment provided to ANANYA MOOKHERJEE
Ref: Your Letter No. Dated: ,
The above patient was admitted in our hospital and was provided with needed medical
treatment. A bill of Rs:50000.00/-(Rupees Fifty Thousand only) raised towards our
services. The bill details are enclosed herewith for your kind perusal
Date Of Admission Date of Discharge Bill No Amount (Rs.)

27/05/2015 01/06/2015 BIPR1506010006 91,379.39
We request your good self to kindly arrange payment at the earliest.
Thanking you and assuring you of our best services at all times.
Yckefthf II ,
HealthCare Pvt Ltd.
, ffiery
_Kt
NEnClosuras,"
Marol Maroshi Road,Andheri(E),Mumbai-59.Ph : 022 -67676767.

www.sevenhillshospital.com E-mail :[email protected]
,
SEVEN HILLS 1-40SPITAL PVT LTD.
DATE
:- 01-06-2015
NAME OF THE PATIENT
:- ANANYA MOOKHERJEE ,
IP NO
: - 1150527006
DATE OF ADMISSION
:- 27/05/15 94F21
:06/15/10:19:01
DATE OF ADMISSION
i
/AMOUNT
DETAIL'S
Final Bill Amount
1
I
91379.00
Final Approved Amount -rom TPA
50000.00
Total Deposit paid by patient
5000.00
(Difference of Sanctioned attioutte'and bill 'aittointeLAi p:er Final App

\
1
41379.00
Security Deposit 10% (AS PER HOSPITAL POLICy )
5000.00
AMOUNT TO BE COLLECTED TO PATIE T
41379.00
Security Deposit will be refundable when the c
s sett d by TPA 0 Insu ance Comp y

Any shortfall in the claim settlement will from TPA will be ecovered f ii the ecurity D posit
# Security Deposit Refund Through NEFT ONLY
For Security Deposit Kindly Call Collection Dept :- Mrs. UCHIT & MR. A IPAL
Landline 022-67676767 ( EXT NO: -\ ,71476 ) Email id :- mumbai.collectioneseve llshospital corn
*Kindly Mention the Belo Security deposit in Favour of

Name of Account Holder:
Name of the Bank
'r
14
Batik Account No
Branch Name
DSC code
if Name of the Payee is different than the Patient Name ( Tick ) the reason
1. P.tieiat does flat have a Bank kiccOlunt.( ) 2. Patient is ininor ( ) 3. Patient is an NRI / Outstation Patient( )
Vipul MedCo ' IIPA Private Limited

515, Udyog Vihar,IPhase 5, Gurgaon, Haryana
Phones: +91 0124 4833900, 4699600 Fax: +91-124-4699611-12,4308211,2438276
Toll Free : 1800 18011 66 and 1800 18011 77
Authorization letter for treatment and guarantee of payment

Date: 16-May, 2015
To,
SEVENHILLS HEALTHCARE PRIVATE LIMITED
MAROL MAROSHI ROAD ANDHERI EAST
MUMBAI
MAHARASHTRA
Pin: 400059
Authorisation No : 04A01C0516926
Claim No: 1601C2195
File No : 16CB0101C0628
Name of
: MS. ANANYA MOOKHERJEE
:tic iary/Patient
1poliey No
: 212800/48/2015/34 field by:411# CONTJNIILIM INDIA ! PRIVATE LIMITED
'ID No
: 0410010017999426
Reason For Hospitalisation : OLITICOME OF DELIVERY
Secondly Disease
Procedure
. 1) NORMAL DELIVERY
Medical Consultant
Guarantee of payment uptoRs. 50000.00 [RUPEES FIFTY THOUSAND ONLY] With Following Capping on Cost Heads:
Spe
1 cial:Isitite: REVERT IN CASE OF LACS
!SpECIAL NOTE:
Please ensure the documents should be submitted to Vipul Medcorp TPA.Pvt Ltd.within 7 days of the discharge of the
beneficiary. Due to non compliance of this provision the claim shall be marked as "NO CLAIM" as per instructions from
the insurers.
'Service Taxhas been withdrawn on service renderid yvef 01.05.2011 as per Govt. Notification No. 30 dated 25.04.2011.
IEJOSPETAL TO PLEASE NOTE:
'1

;
I
10
'Amounts exceeding a total of Ri. 50000.00 RUPEES hiTY THOUSAND ONLY] will require further authorization. I
The hospital must collect the exOess amount (over th!e authorilation amount) directly from the beneficiary at the time of
admission prior to Discharge fromthe Hospital, as pqrliospital Rules and.Regulations (NOT APPLICABLE FOR
PACKAGE RATES).
This authorisation letter is valid for admission between 31-May, 2015 and 05-Jun, 2015
Note: In Case of Stay is Beyond3 Days, Mndly Send the detailed Case Summary.
EXCLUSIONS: (Expenses for the following may please be recovered from the concerned member MS. ANANYA
MOOICHERJEE)
, Registration Fee, Admission Fee, Surcharges, Ambulance Charges, Telephone Expenses, Attendant's stay, Washing
Charges, Private Nurses, Food, Nursery Charges, Misc expenditure and other expenditure which are not related to the
eLk
-",
SevenHills
HOSPITAL
Marol Maroshi Road, Andheri (East), Mumbal - 400 059.
REQUEST FOR CASHLESS HOSPITALISATION

FOR MEDICAL INSURANCE POLICY
Vipul MedCorp TPA Pvt Ltd.
We** Haaikang Sara

DETAI1S OF THETHIRD PARTY ADMINISTRATOR
aJ Name Of TPA/ Instance company:
VIPHL MEDCORP TPA PVT LTD.
b)lbll free phone number:
1800 102 7477
C) FAX

0124-4699611-12 4308211
sithmitawa.pau.nu
b) Derider:
TO EIC FILLED BY THE INSURED / PATIENT
ANANye MOO
kT
Rale /MAIN e)Age: %an 3 0 Mocht 0
f) Cantonal:nit:yr of attending
relative:
HERseE
41 Date of birth:
133 33 5 S 0 6 4
Q. .7/L 211; ; 11 clailluri flioniolt
g) Insured Id Card numben o
9_ 0 1
cl
3 8 la 0
4tooto .0:1 q q 9 i Q 6
h) Polley number/Name Of corporate: 13 A COAT tts1 R. U H EN DIA Employee ID:

/ lie-11th Insurance: ' yet . No Company Name: y
I) Cum:nily do you Nave any other

Give details
k) Do roc, have i family physician: tea Ne I) HMO nub. family physiden

TMContact number, it any:
(PLEASE COMPLETE DECIARATION ON THE REVERSE SIDEOF This FORM)

TO BE FILLED BY THE TREATING DOCTOR / HOSPITAL
a) Nam of the treating doctor: C H
TH- n a y
?Tern( y
3a, 0.71.8
Ii Nature ol ILLNESS / OHM, "Dv rot

with presenting complaints
e) Duration of the present ailment
056,y ;
b) Conlon nurnben
d )Rolevant clinical findings:
11. Past history

of present
aliment linty:
Ana I. Date of nro rontultalion
pYhnL
Katmai; f ir
L ICO 10 Code:
Macill Maar_end
EPtroposed line of treauntin
Le....--14111 Mearigtmeni
intamwecare
b) lf Ineettigailan /or Medical

PLinegement provide details
LbCD 10 PCS Code:
ft If other treatment$ provide

details
1) In citse otarcident:
It) How did Inlury occur:
1) In eme cd Alatemlip
1 P
WI Reported to Police:
II) Dale 011ITIOITI
I/bill RTA: . yes
v)Iniury/DIseasecaiteed due to subeianer abuse/alcohol consumption We

0
Date of Delivery: a / /
NI, IV) FIR No:
AM I lie
if) Test conducted to establish thit :
fit Yes attach reports)
0 61 r
Mandatom: Past Maim of any chronic
Details of the patient admitted

a) Date of admission:
kolb.41kitallUr keNuntit
!Inutile ar drutarlmlnliglratIod:
L6e-6/ go,,,,t
Rind, name of surgery
Invtilikettun
3 go 5 a, i. j b)TIme:
II ri.ilnre (mount net)
Diabetes
Heart Disease
4) Is Chit nntmergenty/a pi/tonic, host I tone:sum trent?

d) rspectird no. Nays stay In hotpltsh
Darrirmy
5 nap el Rom TYPe
tJ PerDay Room Rent *Nursing al Service Charges Patient', Dice
illaperted cosi for Investigation diem:es-11m te

is) ICH Charges:
1) OTatarget
LSI.
Ilypertension
PeClInAm
Hype:I-Opt:le:Was
OsteoarthrItls
Rs
YhtehkAdra-; rqs S 66 o
Asamm/aWD/BromM
Gower
(fir P6 PO.A.k.lad,/,. Rs
Its
Any HIV or gRiftwAtVaiiii nti.
l) Proles-Am:al fees Surgeon Anesthetist Pees conothati on (barges RS
hproy
-*tat
:31,14 00
fthinCigt LID
OCA5t)
11;1,,
550 re,.aGedi
BO pee,
Sljt
Aftr"
Patient Transaction Details
6/1/201
5
II' final billing
43
Patient Name
ANANYA MOOKIIEFUEE
Patient No
-- .
EMR No
150527006
BIliDate
MCI42400070
Registration Date 27/05/2015 05:01:21
Category
SPONSOR
Ago ( Gender )
30Y 5M 013(F)
Patient Type
- . .
Employee Id
Employee Name
Patient Relation
01/06/2015 10:1001
. .
IP
Sponsor
VIPUL MEOCORP TPA
Bill Type
-Payment Type
NORMAL
Start 8 End Dato
27/05/2015 05:01:21
Cash & Credit

/201510:1901
Analysis
Package: (VACCUN DELIVERY) I Duration (3) From (28/05/2015) ITo (30/05/2015) I Limit (66,000.00)
Sponsor/Third Party Information

Third Party Name
Sponsor Name
VIPUL MEDC RP TPA
Service
Payments ft Receipts
Stio
11
Sponsor C egory TPA
Amount Rs.
Services / Description
PAYMENT AND RERINI35
Total
Billed P 'Ilion
5000.00!
SNo
5,000.00
I DI
1 -,..t iSTRATII
, LA cuARaES
Discount
'vices / Description
Amount Rs
1 50 .00
24D00
680.00
66,000.00
MISC: LAMEOUS GD/

6
DOCT - CONSULTATION
i PROC:f 'ia.
!. ROOM -.:
I PHARMAC
170.00
6.550.00
8,940.00'
000.00
4 39
Total
913 9
Unbilled Position
http://10.129.41.194:9999/Medpro4/patientBilling.do?subAction=patientBillDetailsInit&ID=1150527006
Total BIll Amount Rs
Payment and Refunds Rs
Net Amount Rs
1
91,379.391
5 000.001'
86,379.3M
1/2
IN-Patient Bill Breakup
SevenHills
90 8 PITAL

Patient No: 1150527006 UHID:
MCH2400076 Patient Name: ANANYA MOOKHERJEE Age(Sex) 30Y 5M OD ( FEMALE )

FinalBill No: BIPR1506010006 Bill Date:
01-06-2015 Sponsor:
VIPUL MEDCORP TPA Pay Type: CREDIT

Account Head :
DOCTOR CONSULTATION
BIII No
SNo
Ser.Prov.

Bed No - Type:
6118 - SINGLE
Dr Name
Service/Item
Amount(Rs.) 6,550.00
I No's I Amount I Discount I Total(Rs.) )
Bill Status: ACTIVE

1 5015052701248NA(SER02817)
27/05/2015 CHITWAN DUBEY
MD /MS CONSULTATION CHARGES
850.00
0.00
850.00
2 5015052700693NA(SER02817)
3 S015052700859NA(SER04152)
850.00
0.00
850.00
27/05/2015 MEDICAL OFFICER
RMO CHARGES
200.00
0.00
200.00
29/05/2015 ZINAL UNADKAT
850.00 0.00
( 27/0512015
4 S015052901059PA(SER02817)
1.900.00
( 29/05/2015
5 5015053000452PA(5ER02617)
850.00
850.00
30/05/2015 SWAT! TEMKAR
850.00 0.00
30/05/2015
860.00
ssozo
6 S015053100654PA(SER02817)
850.00
0.00
850.00
7 S015053100947PA(5ER02817)
850.00
0.00
850.00
8 S015053100091PA(5ER04152)
RMO CHARGES
200.00
0.00
200.00
9 S015053101019NA(5ER02817)
MD (MS CONSULTATION CHARGES
850.00 0.00
10 S015053101020NA(5ER04152)
RMO CHARGES
200.00
31/05/2015
1,900.00
0.00
01/0612015
850.00
200.00
1,050.00 )

Account Head :
MISCELLANEOUS GENERAL

APPROVED TOTAL(Rs.)

NET AMOUNT(Rs.) :

Bed No - Type:
6118 -SINGLE
AmounaRs ).

Bill No
I Ser.Prov. I
Dr Name
SNo I

Service/Item
6,550.00
6,550.00
170.00
I Ws I Amount I Discount I Total(Rs.)
Bill Status: ACTIVE

1 5015052700270NA(SER03342) 27/05/2015 MEDICAL OFFICER
SURGICAL SHAVING / HEAD SHAVING
170.00 0.00
1
170.00
27/05/2015
170.00)

Account Head :
REGISTRATION

BIII No
SNo

APPROVED TOTAL(Rs.) :

NET AMOUNT(Rs.) :

Bed No - Type:
6118 - SINGLE
Amount(Rs.): 240.00

Ser.Prov. I Dr Name

Service/Item
170.00
170.00
I No's I Amount I Discount I Total(Rs.)
BM Status: ACTIVE

1 TICW115052700601(SER02589) 27/05/2015 CHITWAN DUBEY
ADMISSION CHARGES

1
240.00 0.00
240.00
27/05/2015
240.00)

Account Head :
PROCEDURES

SNo
13111 No


NET AMOUNT(Rs.) :

Bed No. Type:
6118- SINGLE
Amount(Rs )

Ser.Prov, Dr Name

Note: MI the Amounts are Show, In Rupees

Service/Item
240.00
240E0
8,940.00
Service/item Count 12 Page Total(Rs.): 6,960.00
Page 1 of 5
SevenHills
H 08P IT A I..

MCH2400076 Patient Name:
ANANYA MOOKHERJEE Age(Sex): 30Y 5M OD (F)

01-06-2015 Sponsor:

(Account Head : PROCEDURES
Bill No
SNo
1 Ser.Prov.

Bed No - Type: 6118 - SINGLE
Service/Item
Dr Name
Amount(Rs.):
I No's 1 Amount
8,940.00
I Discount 1 Total(Rs.)
ACTIVE
Bill Status:
2 6015052700274NA(5ER02883)
27/05/2015 CHITWAN DUBEY LR RECOVERY ROOM CHARGES PER 1

DAY
27/05/2015 CHITWAN DUBEY HOT - PROCEDURE CHARGE
1
3 5015052701170NA(SER04951)
27/05/2015 MEDICAL OFFICER NEONATAL SENSORY TEST (NST) 1
920.00 0.00 920.00
4 S015052700268NA(SER04951)
920.00 0.00 920.00
6 6015052700996NA(SER02906)

27/05/2015 MEDICAL OFFICER I. V. INJECTION / CANNULLA INSERTION 1
PROCEDURE CHARGE
27/05/2015 MEDICAL OFFICER SIMPLE ENEMA - PROCEDURE 1
7 5015052700273NA(SER02906)
27/05/2015 MEDICAL OFFICER SIMPLE ENEMA - PROCEDURE
160.00 0.00 160.00
8 S015052701367NA(SER04951)
920.00 0.00 920.00
28/05/2015 CHITWAN DUBEY HOT - PROCEDURE CHARGE
160.00 0.00 160.00
S015052900918NA(SER05724)
5 S015052700269NA(SER02884)
5,200.00 0.00 5,200.00

200.00 0.00 200.00
300.00 0.00 300.00

160.00 0.00 160.09
i 27/05/2015
9 S015052800418NA(5ER02883)
8780.00)
( 28/05/2015
160.00
APPROVED TOTAL(Re.) :
8,940.00
NET AMOUNT(Rs.) :
Bed No - Type: 6118 SINGLE
Account Head : LAB CHARGES

( SNo Bill No 1 Ser.Prov.
Dr Name
Service/Item
8,940.00
Amount(Rs ): 680.00
1 No's 1 Amount 1 Discount 1 Total(Rs.)
BIII Status: ACTIVE

COMPLETE BLOOD COUNT (CBC)
1 L015052700043NA(SER00133) 27/05/2015 MEDICAL OFFICER

2 L015052700043NA(5ER02560) 27/05/2015 MEDICAL OFFICER
BLOOD GROUPING

CROSS MATCHING
3 L015052700043NA(5ER02565) 27/05/2015 MEDICAL OFFICER

27/05/2015

480.00
0.00
480.00

120.00
0.00
120.00

80.00
0.00
80.00
680.00

APPROVED TOTAL(Rs.)

NET AMOUNT(Rs.) :

Bed No - Type:
6118 - SINGLE
Amount(Rs.). 3,000.00

Account Head :
ROOK RENT

( SNo I
Bill No
Ser.Prov. 1
Dr Name

Service/Item
680.00
680.00
1 No's 1 Amount 1 Discount 1Total(Rs.)
3111 Status: ACTIVE

1 S015053001499NA(SER02823) 31/05/2015 CHITWAN DUBEY
BED CHARGES

( 31/05/2015
3,000.00

3,000.00

NET AMOUNT(Rs.) :
3,000.00

Bed No - Type:
6118 - SINGLE
Amount(Rs ) 4,294.39
( Account Head : PHARMACY

( SNo Bill No

1 31300.00 0.00
3,000.00
Ser.Prov. 1
Dr Name
Service/Item
1 No's1 Amount I Discount 1Total(Rs.) )
BIll Status: ACTIVE

1
T1P1505270037(ZDT-2495)
MISOPROSTOL 200MCG TAB (TECTOR

200 TABN TAB( Exp. :11-2016)
T1P1505270106(14Y029KP)
T1P1505270080(15024308)
T1P1505270080(505103UJD1)
TIP1505270106(420-09015S)
METHERGIN 1ML INJ( Exp. :10-2016)

STOPCOCK WITH EXTENSION LINE
10CM( Exp. :01-2018)
SYRINGE WITH LUER LOCK 10CC,W/0
NEEDLE UNO LOK( Exp. :12-2019)
PITOCIN INJ 0.5ML 10%0.5( Exp. :08-2016)
T1P1505270309(E-189)
TIP1505270037(14AE21)
Note: All the Amounts are shown In Rupees
PROCTOCLYSIS ENEMA 100ML( Exp. :0E2016)

EPIDOSIN 1ML INJ( Exp. :11-2017)
Service/Item Count 20 Page Total(Re.): 13,128
68.00
0.00
68.00
14.92
0.00
14.92
150.00
0.00
150.00
15.00
0.00
75.00
20.99
0.00
104.95
48.00
0.00
48.00
0.00
47.46
\\Ptage 2 of 5
If I\
K
/

SevenHills
HO 3 Fl TAI.

MCH2400076 Patient Name: ANANYA MOOKHERJEE Age(Sex): 30Y 5M OD ( F )

FinalBill No: BIPRI506010006 Bill Date:
01-06-2015 Sponsor:

Account Head :
PHARMACY

Bed No - Type:
6118 SINGLE

BIII No
I Ser.Prov. Dr Name
t Pio I

Service/Item
Arneunt(Rs.) 4,294.39
I No's j Amount I Discount I Totaglis.)
BIII Status: ACTIVE

MEDICAL OFFICER
MISOPROST 25MCG TAB 1X4( Exp. :062016)

RDOL 1ML INJ(TRAMADOL)( Exp. :112016)
CATHETER FOLEYS, TWO WAY, 14 FR
(RUSCFI)( Exp. :08-2019)
T1P1505270037(GH50281)
27/05/2015
T1P1505270037(A14666)
10
T1P1505270080(14102)
11
T1P1505270598(9070477)
FORTWIN INJ 1X1ML( Exp. :12-2016)
12
T1P1505270037(MHE-464)
27/05/2015
MEDICAL OFFICER
DROTIN INJ 2ML( Exp. :11-2016)
13
TIP1505270037(9070462)
27/05/2015
MEDICAL OFFICER
FORTWIN INJ 1X1ML( Exp. :11-2016)
14
TIP1505270037(3300915)
18.00
RINGER LACTATE VIAFLEX BAXTER

500ML( Exp. :06-2016)
GLOVES SURGICAL, STERILE, SIZE-6(
Exp. :11-2017)
INJECTION NEEDLE 16G 1112 INCH( Exp.
:02-2020)
0.00
18.00
12.30
0.00
24.60
108.00
0.00
108.00
5.58
0.00
5.58
14.77
0.00
44.31
5.58
0.00
11.16
57.75
0.00
288.75
50.00
0.00
200.00
3.00
0.00
12.00
15
TIP1505270080(141205)
16
T1P1505270080(135515)
17
TIP1505270080(N/A)
UNDER PAD(23*X36)( Exp. :05-2019)
10
55.00
0.00
550.00
18
TIP1505270080(1064)
SURGICAL BLADE, SIZE 23( Exp. :112015)
3.55
0.00
3.55
19
TIP1505270080(01)
APRON PLASTIC, DISP.( Exp. :02-2018)
60.00
0.00
300.00
20
T1P1505270037(821D804810)
27/05/2015
MEDICAL OFFICER
NORMAL SALINE 09%

100ML(FRESINUS)( EXP. :03-2018)
9.37
0.00
18.74
21
T1P1505270037(IPMDA2501)
27/05/2015
MEDICAL OFFICER
KENADION 1MG/0.5ML INJ( Exp. :12-2016)
12.00
0.00
12.00
22
T1P1505270598(NPA0060)
PHENERGAN 2ML INJ( Exp. :01-2018)
6.68
0.00
6.68
23
TIP1505270080(140701)
SHAVING SET, DISPOSABLE( Exp. :062017)
32.00
0.00
96.00
PRIMIGYN 3GM GEL( Exp. :09-2016)
24
TLD1505270001(BB1414)
25
T1P1505270037(1051573)
26
T1P1505270037(E-189)
27
T1P1505270080(4234270)
27/05/2015
28
T1P1505270080(22990)
MEDICAL OFFICER
247.00
0.00
247.00
26.51
0.00
26.51
48.00
0.00
48.00
160.00
0.00
320.00
I.V.SET. ADULT, VENTED( Exp. :02-2019)
98.00
0.00
196.00
36.00
0.00
36.00
4.50
0.00
9.00
NORMAL SALINE 0.9% 5091iAL (NIRLIFE)(

Exp. :02-2018)
PROCTOCLYSIS ENEMA 100ML( Exp. :062016)
I.V.CANNULA WITH WINGS AND
INJECTION PORT 20G X 32MM, BDVENFLOW PRO( Exp. 08-2017)
29
T1P1505270080(1501436)
INFANT FEEDING TUBE 7( Exp. :12-2019)
30
T1P1505270080(508055WS02)
31
T1P1505270080(N15C092)
SYRINGE 5CC, W/O NEEDLE DISPOVAN(

Exp. :01-2020)
URINE COLLECTION BAG, ADULT( Exp.
:02-2019)
108.00
0.00
108.00
32
TIP1505270037(51315015)
BUSCOGAST 1ML INJ( Exp. :02-2017)
10.98
0.00
32.94
33
T1P1505270080(RM14K078)
CORD CLAMP( Exp. :10-2018)
25.00
0.00
25.00
34
T1P1505270080(141205)
50.00
0.00
150.00
35
T1P1505270080(12551D)
2.00
0.00
8.00
36
TIP1505270080(02511M)
27/05/2015
2.00
0.09
6.00
37
TIP1505270080(431016AG32)
4.50
0.00
9.00
38
T1P1505270080(02563C)
GLOVES SURGICAL, STERILE. SIZE-7(

Exp. :11-2017)
INJECTION NEEDLE 18G 11/2 INCH,
DISPOVAN( Exp. :02-2020)
INJECTION NEEDLE 26G 1 1/2 INCH,
SYRINGE -ICC, W/O NEEDLE DISPOVAN(
Exp. :07-2019)
INJECTION NEEDLE 230 1 INCH,
2.00
0.00
6.00
39
T1P1505270080(RM15D042)
OXYGEN MASK, ADULT( Exp. :03-2019)
150.00
0.00
150.00
40
TIP1505270080(1505)
530.00
0.00
530.00
41
T1P1505270080(1503463)
27/05/2015
42
T1P1505270080(507021W5F2)
43
T1P1505270080(507052WS1-12)
SOLUS SWIFT UNDYED 2-0, 140CM 1/2

CRB, 1/2 CRC, 40MM - LNW 2777( Exp. :01
-2020)
SUCTION CATHETER 8(GS-2006)( Exp. :02
-2020)
SYRINGE 2CC, W/O NEEDLE DISPOVAN(
Exp. :01-2020)
SYRINGE 5CC. W/O NEEDLE DISPOVAN(
Exp. :01-2020)
Note: NI the Amounts are Shown In Rupees
MEDICAL OFFICER
MEDICAL OFFICER
Seri/Ice/Item Count 36 Page Total(Rs.): 3,666.82
45.00
3
3.50_
4.50
0.00
45.00
0.00
10.50
dm
4.50
%Ye-
Page 3 of 5
SevenHills
ft OSPITA I.

MCH2400076 Patient Name: ANANYA MOOKHERJEE Age(Sex): 30Y 5M OD ( F )

01-06-2015 Sponsor:

Account Head :
PHARMACY
SNo

Bed No - Type:
6118- SINGLE

Bill No
Dr Name
I Ser.Prov. I

Service/item
Amount(Rs ). 4,294.39
I Nee I Amount I Discount I Total(Rs.)
Bill Status: ACTIVE

44 T1P1505270037(10N-622)
45 TIP1505270037(NPA0060)
46 TIP1505270080(141205)
27/05/2015
MEDICAL OFFICER
47 TIP1505270080(150415)
27/05/2015
MEDICAL OFFICER
ONDANSETRON 2ML INJ (ONDET 2ML

INTAS)( Exp. :07-2016)
2 16.30 0.00
32.60
PHENERGAN 2ML INJ( Exp. :01-2018)
2 6.68 0.00
13.36
GLOVES SURGICAL, STERILE, SIZE-6(

Exp. :12-2017)
GLOVES SURGICAL, STERILE, SIZE-6.5(
1 50.00 0.00
50.00
Exp '03-2018)
4 50.00 0.00
200.00
t 27/05/2015
4,471.11)
48 TIP1505310422(CFTB5B3)

31/05/2015
CEFOPRIM 500MG TAB 1X4( Exp. :012017)
313.50 0.00 313.50

313.50

4,784,61
Bill Status: PARTIAL RETURN

49 S1P1505280179(RM150042)
OXYGEN MASK, ADULT( Exp. :03-2019)
1 150.00 0.00
150.00
50 8IP1505280179(14102)
CATHETER FOLEYS, TWO WAY, 14 FR

(RUSCH)( Exp. :08-2019)
1 108.00 0.00
108,00
51 SIP1505280181(SB15015)
BUSCOGAST 1MLINJ( Exp. :02-2017)
2 10.98 0.00
21.96
52 S1P1505280181(3300915)
1 57.75 0.00
57.75
53 SIP1505280181(1C51573)
1 26.51 0.00
26.51
54 51P1505280179(N15C092)
1 108.00 0.00
108.00
55 SIP1505280181(GH50281)
RINGER LACTATE VIAFLEX BAXTER

500ML( Exp. :06-2016)
NORMAL SALINE 0.9% 500ML (NIRLIFE)(
Exp. :02-2018)
URINE COLLECTION BAG, ADULT( Exp.
:02-2019)
MISOPROST 25MCG TAB 1X4( Exp. :062010
1 18.00 0.00
18.00
28/05/2015
490.22
PARTIAL RETURN TOTAL(Rs.)
490.22
NET AMOUNT(Rs.) :
Account Head :
PACKAGES
SIII No
SNo I
Bed No - Type:
I Ser.Prov. I
Dr Name
6118 - SINGLE
Service/Item
4,294.39
, Amount(Rs.)' 66,000.00
BM Status: ACTIVE
1 8015052900971NA(SER04099) 28/05/2015 CHITWAN DUBEY
VACCUM DELIVERY
1 66,000.00 0.00 66,000.00
28/05/2015
66,000.00
66,000.00
NET AMOUNT(Rs.) :
Account Head :
SNo I
Bed No - Type:
DIET
Bill No
I Ser.Prov. I
Dr Name
6118- SINGLE
Service/Item
66,000.00
Amount(Rs.) 1,505.00
13111 Status: ACTIVE

1 8015052700742NA(SER04776)
27/05/2015 CI-IITWAN DUBEY
LUNCH
2 6015052700999NA(5ER05979)
READYMADE COFFEE
250.00 0.00
49.00 0.00
t 27/05/2015
250.00
49.00
299.00
3 6015052900782NA(SER06016)
29/05/2015
CHITWAN DUBEY
PEPSI PET
66.00 0.00
66.00
4 8015052900411NA(SER05978)
29/05/2015
CHITWAN DUBEY
READYMADE TEA
22.00 0.00
22.00
5 8015052900782NA(SER04935)
29/05/2015
CHITWAN DUBEY
MISC-FOOD SERVICES
120.00 0.00
120.00
6 6015052901252NA(SER06032)
29/05/2015
CHITWAN DUBEY
RICE PLAIN
62.00 0.00
62.00
7 S015052900780NA(SER06033)
29/05/2015
CHITWAN DUBEY
FRIED RICE VEG
103.00 0.00
103.00
8 8015052900780NA(SER04935)
29/05/2015
CHITWAN DUBEY
MISC-FOOD SERVICES
1 >511011 0.00
150.00
BliteNvr: 523.00)
29/05/2015
Note: All the Amounts are Show In Rupees
Service/Item Count 21 Page Total(Rs.):
66,941. 41,
it.
4 of 5
EE
ast,

SevenHills
NORMAt

1150527006 UHID:
MCH2400076 Patient Name: ANANYA MOOKHERJEE Age(Sex): 30Y 5M OD ( FEMALE )

01-06-2015 Sponsor:
Patient No:

( Account Head :
DIET
Bed No - Type:
6118- SINGLE

SNo I
Bill No
Ser.Prov. I
Dr Name
Service/Item
Amount(Rs.): 1,505.00
Bill Status: ACTIVE

9 S015053000416NA(SER04866)
IDLI SAMBER
10 S015053000879NA(SER04935)
MISC-FOOD SERVICES
11 S015053000359NA(SER05978)
12 5015053000879NA(SER06033)
13 5015053000882NA(SER04935)
14 S015053000879NA(SER06016)
40.00
0.00
40.00
120.00
0.00
120.00
READYMADE TEA
22.00
0.00
22.00
FRIED RICE VEG
103.00
0.00
103.00
MISC-FOOD SERVICES
150.00
0.00
150.00
PEPSI PET
66.00
0.00
66.00
15 5015053100390NA(5ER05978)
READYMADE TEA
22.00
0.00
16 5015053100390NA(5ER04866)
IDLI SAMBER
40.00
0.00
40.00
17 6015053100627NA(5ER04775)
LUNCH
120.00
0.00
120.00
30/05/2015
501.00
I31/05/2015
22.00
182.00
APPROVED TOTAL(Re.) :

Sno Account Head

1 DOCTOR CONSULTATION

2 REGISTRATION

3 MISCELLANEOUS GENERAL

4 PROCEDURES

5 LAB CHARGES

6 ROOM RENT

7 PHARMACY

8 PACKAGES

9 DIET
NET AMOUNT(Rs.) :
1,505.00
1,505.00
Amount(Rs.)
6,550.00
240.00
170.00
8,940.00
680.00
3,000.00
4,294.39
66,000.00
1,505.00

Billed Amount(Rs.):
91,379.39

Advance Amount:(-)
41,379.00

Total Amount(Rs.):
50,000.39
Round Amount(Rs.):
-0.39

Net Amount(Rs):
50,000.00
Net Payable In Words: (Rupees)FIfty Thousand only

Note: Ali the Amounts are Shown In Rupees
Service/item Count 9 Page Total(Rs.): 683.00
Page 5 of 5
r.
SevenHills
SevenHills
HOSPITAL
Generated At OP/WM 5 0947
In Address 10 129 SO 155
HGT Record
SP1TAL
Generated Ely DCHHEOA
Calendar Date: All Calendars
UHID: MCH2400076
Patient No: 1150527006 Bed No( LAD): 6118 (L6 B8 SINGLE ROOMS)
Patient Name: ANANYA MOOKHERJEE
Age(Sex): 30Y 5M OD(F) Admission Date: 27/05/2015 05:01

Dis Date:
01/06/2015 11:45
Doctor: SWATI TEMKAR

Sno
1
2
Date &Time
27/05/2015 05:15
AM
28/05/2015 06:05
AM
ago I of I
Bed No
Test Description
3105
HOT- PROCEDURE CHARGE
90 mg/ell
MONISHAT
3108
HOT - PROCEDURE CHARGE
106 mg/di
PRATIBHA
Result
UOM
SevonHilts Health CIlyMarot Maroshl RoadAndherl(East),Mumbel-000 059.Ph:022-67676767,vernv.sevenhIllshosoltal.com

kAIIL
baal
0 11.471.
.41014461
Insulin

Entered By
C-47
SevenHills
HOSPITAL
Department of Laboratory Medicine
Patient Name
ANANYA MOOKHERJEE
Age ( Sex)
30Y 5M ( FEMALE)
Doctor
MEDICAL OFFICER ( VIVEK KUMAR DWIVEDI )
Patient No
1150527006
LO No
L015053000088
Collection Date 30-05-2015 07:20
UHID
MCH2400076
Requisition No
RHA150504066
Received Date
Sponsor
VIPUL MEDCORP TPA
Requisition Date 30-05-2015 07:19
Authorization Date 30-05-2015 13:05

HAEMATOLOGY

Result
UOM Biological Reference Range

Method ( Flow Cytometry ) II Specimen ( BLOOD)
Red Blood Count
3.17
10^6/u1
3.8-4.8
Haemoglobin
gm/dL
12-15
Haematocrit
27.2
MCV
85.8
Fl
83-101
. MCH
29.0
Pg
27-32
MCHC
33.8
gm/CIL
31.5-34.5
RDW-SD
40.7
Fl
39-46
RDW-CV
13.3
Platelet Count
211
MPV
9.3
POW
10.2
Total Leucocyte Count
11.43
36-46
11-16
1043/u1
150-410
109/u1
4-11
DIFFERENTIAL COUNT
Neutrophils
68
40-80
Lymphocytes
23
15-40
Monocytes
05
2-10
Eosinophils
03
1-6
Basophils
00
1-2
Comment
Myelocytes-01%
Polychromatic cells noted
NOTE: Blood counts performed on fully automated 5-part differential
counter Sysmex XT-2000i
The report relates onty to the sample submitted In our laboratory.

These reports are for assisting Medical pmfessicools In the diagnosis and management of the patient and should be correlated dinicalty.
a Ws Is a system generated repcd.Persaud signature may not be required.
OEMS.,
MitO1.44112
el S
01911111710

Page 1 of 2
1\
SevenHills
HOSPITAL
Department of Laboratory Medicine
Patient Name
ANANYA MOOKHERJEE
Age ( Sex)
30Y 5M ( FEMALE)
Doctor
MEDICAL OFFICER ( VIVEK KUMAR DWIVEDI )
Patient No
1150527006
LO No
L015053000088
Collection Date 30-05-2015 07:20
UHID
MCH2400076
Requisition No
RHA150504066
Received Date
Sponsor
VIPUL MEDCORP TPA

HAEMATOLOGY
Result
Dr.MAYURI SHENDE
MBBS , DNB (Pathology) .
Junior Consultant In Pathology
*** END OF REPORT
The report relates only to the sample submitted In our laboratory.

Masa reports are for assisting medical pr ofessionals In the diagnosis and management of the patient and should be correlated dnicalty.
This Is a system generated reccelPersond signature may not be required.

1111111.
1.1
.61M. WOMB
01401414/31

Pap 2 of 2
SevenHills
HOSPITAL
Department of Laboratory
_ Medicine
Patient Name ANANYA MOOKHERJEE
Age ( Sex)
30Y 5M ( Female)
Doctor
MEDICAL OFFICER ( PREETI )
Patient No
1150527006
LO No
L015052700043
UHID
MCH2400076
Requisition No RBK150501775
Sponsor
V1PUL MEDCORP TPA
Collection Date
27-05-2015 06:18
Received Date
Au ti
thorzaon
i
Date
27-05-2015 14:38
BLOOD BANK
BLOOD GROUPING
Method (Erythrocyte magnetization )11 Specimen ( BLOOD )
ABO
0
Rh
POSITIVE
Dr.M V DOSHI
MD, DNB.
MD(Bom),DNB(PatholOgy),MNAMS
m END OF REPORT ***
Page 1 of 1
The report relates only to the sample submitted In our laboratory.
These reports are for assisting medical professionals in the diagnosis end managemerd of the patient and should be correlated clinically.
This Is a aYsfem generated rapan.Personm signature may not be required.

MABI.
01001
0.
11.1914.11
Moroi Maroshi Road, Andheri (East), Mumbai - 400 059.

.-t\
SevenHills
HOSPITAL
_ Medicine
Patient Name
ANANYA MOOKHERJEE
Age ( Sex)
30Y 5M ( FEMALE)
Doctor
Patient No
1150527006
LO No
L015052700043 '
Collection Date
UHID
MCH2400076
Requisition No
RHA150503616
Received Date
Sponsor
VIPUL MEDCORP TPA
Requisition Date
27-05-2015 06:16
27-05-2015 06:16

HAEMATOLOGY

Result

Method ( Flow Cytometn/ ) fi Specimen ( BLOOD )
Red Blood Count
4.10
10"6/u1
3.8-4.8
Haemoglobin
11.9
gm/dL
12-15
Haematocrit
35.2
MCV
85.9
Fl
83-101
MCH
29.0
P9
27-32
MCHC
33.8
gm/dL
31.5-34.5
RDW-SD
40.9
Fl
39-46
RDW-CV
13.2
11-16
Platelet Count
261
10A3/u1
,150-410
MPV
9.4
POW
11.1
Total Leucocyte Count
10.90
10^3/u1
4-11
DIFFERENTIAL COUNT
Neutrophils
72
Vt.
40-80
Lymphocytes
18
15-40
Monocytes
07
2-10
Eosinophils
02
1-6
Basophils
00
1-2
Comment
Myelocytes-01%
36-46
Few Polychromatic cells noted

NOTE- Blood counts performed on fully automated 5-part differential
counter Sysmex XT-2000i
The report Mates ordy to the sample sutanitted know laboratory.

These reports are for assisting medical professionals tn the diagnosis and management of the patient and Should be Consisted MnicaltY.
' This, a system generated reoort.Personsl signature may not be iv:aired.
fl Di
1.4.3.091. OwnOstP0

Page 1 of 2
rA7
SevenHills
HOSPITAL
_ Medicine
Patient Name
ANANYA MOOKHERJEE
Age ( Sex)
30Y 5M ( FEMALE)
Doctor
Patient No
1150527006
LO No
L015052700043
Collection Date
UHID
MCH2400076
Requisition No
RHA150503616
Received Date
Sponsor
VIPUL MEDCORP TPA
Requisition Date
27-05-2015 06:16
27-05-2015 06:16

HAEMATOLOGY
Result
Dr.MAYURI SHENDE
MBBS DNB (Pathology) .
Junior Consultant In Pathology
END OF REPORT
' The report Metes only to the sample subtitled In ,Jr laboratory.
These mports are for assisting Medical professionals In the diagnosis and management of the patent and should be correlated cilifically.
This tee system generated report.Personal signature may not be required.
01111
CS,
1.401.40:1

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-Z

IN PATIENT - CREDIT FINAL BILL

Age(Sex): 30Y 5M (F)

Sponsor: VIPUL MEDCORP TPA

Relation With Patient:

Jmission Date: 27/05/2015 05:01

Total Amount (Rs.)

Net Amount (Rs.)

Marol Maroshi Road, Andheri (East), Mumbal - 400 059.

DIAGNOSIS : SUPERVISION OF NORMAL PREGNANCY - Z34

Marol Maroshi Road, Andheri (East), Mumbai - 400 059.

LIE- LOCHIA HEALTHY

Marol Maroshi Road, Andheri (East), Mumbai - 400 059.

Authorized On: 32115/2015 14:31

End of Discharge Summary

No:SHH/AcctNIPUL MEDCORP TPA

Date Of Admission Date of Discharge Bill No Amount (Rs.)

Marol Maroshi Road,Andheri(E),Mumbai-59.Ph : 022 -67676767.

NAME OF THE PATIENT

Final Approved Amount -rom TPA

Total Deposit paid by patient

(Difference of Sanctioned attioutte'and bill 'aittointeLAi p:er Final App

Security Deposit 10% (AS PER HOSPITAL POLICy )

AMOUNT TO BE COLLECTED TO PATIE T

Security Deposit will be refundable when the c

s sett d by TPA 0 Insu ance Comp y

*Kindly Mention the Belo Security deposit in Favour of

Vipul MedCo ' IIPA Private Limited

Authorization letter for treatment and guarantee of payment

IEJOSPETAL TO PLEASE NOTE:

REQUEST FOR CASHLESS HOSPITALISATION

Vipul MedCorp TPA Pvt Ltd.

We** Haaikang Sara

aJ Name Of TPA/ Instance company:

VIPHL MEDCORP TPA PVT LTD.

b)lbll free phone number:

1800 102 7477

TO EIC FILLED BY THE INSURED / PATIENT

Rale /MAIN e)Age: %an 3 0 Mocht 0

Q. .7/L 211; ; 11 clailluri flioniolt

g) Insured Id Card numben o

h) Polley number/Name Of corporate: 13 A COAT tts1 R. U H EN DIA Employee ID:

I) Cum:nily do you Nave any other

k) Do roc, have i family physician: tea Ne I) HMO nub. family physiden

(PLEASE COMPLETE DECIARATION ON THE REVERSE SIDEOF This FORM)

a) Nam of the treating doctor: C H

Ii Nature ol ILLNESS / OHM, "Dv rot

e) Duration of the present ailment

d )Rolevant clinical findings:

11. Past history

Ana I. Date of nro rontultalion

EPtroposed line of treauntin

b) lf Ineettigailan /or Medical

LbCD 10 PCS Code:

ft If other treatment$ provide

It) How did Inlury occur:

II) Dale 011ITIOITI

I/bill RTA: . yes

v)Iniury/DIseasecaiteed due to subeianer abuse/alcohol consumption We