Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
DETAILS OF HOSPITAL
c) Type of Hospital:
a) Hospital ID:
S
Network :
R
Non Network :
SECTION A
e) Date of birth: D
e) Qualification:
g) Phone No.
f) Date of Admission:
j) Type of Admission:
Emergency
Planned
Discharge to home
Day Care
c) Gender: Male
g) Time: H H
Female
d) Age: Years
Months M
h) Date of Discharge:
k) If Maternity
Maternity
i) Date of Delivery:
SECTION B
b) IP Registration Number:
Deceased
a)
Description
b)
ICD 10 PCS
I. Primary Diagnosis
i. Procedure 1:
ii. Procedure 2:
iii. Co-morbidities:
iii. Procedure 3:
iv. Co-morbidities:
Description
SECTION C
ICD 10 Codes
c) Pre-authorization obtained:
Yes
No
d) Pre-authorization Number:
Yes
No
Self-inflicted
ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this:
Yes
Yes
No
Yes
No
v. FIR No.
Investigation reports
ECG
Pharmacy bills
SECTION D
State:
Pin Code:
d) Hospital PAN:
b) Phone No.
e) Number of inpatient beds
iii. Others:
i. OT
Yes
No
ii. ICU
Yes
No
SECTION E
City:
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact,
our right to claim under this claim shall be forfeited.
Date:
SECTION F
GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)
FORMAT
DESCRIPTION
DATA ELEMENT
b)
Hospital ID
c)
Type of Hospital
e)
Qualification
f)
Enter the registration number of the doctor along with the state code
g)
Phone No.
c)
Name of Patient
b)
IP registration Number
c)
Gender
d)
Age
e)
Date of Birth
f)
Date of Admission
g)
Time
h)
Date of Discharge
i)
Time
j)
Type of Admission
k)
If Maternity
l)
M)
Date of Delivery
Gravida Status
b)
ICD 10 Code
Primary Diagnosis
Additional Diagnosis
Co-morbidities
ICD 10 PCS
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
Open text
c)
Pre-authorization obtained
Tick Yes or No
d)
Pre-authorization Number
As allotted by TPA
e)
Open text
Tick Yes or No
Cause
f)
Tick Yes or No
Medico Legal
Reported to Police
Tick Yes or No
Tick Yes or No
FIR No.
Open text
Address
b)
Phone No.
c)
Enter the registration number of the Hospital obtained from local body
like City Corporation / Municipality
d)
Hospital PAN
e)
Digits
f)