PARK MEDICLAIM TPA PVT LTD

THIRD PARTY ADMINISTRATOR-HEALTH SERVICES (AN ISO 9001:2008 CERTIFIED COMPANY) Authorisation For the Cashless request for Hospitalisation under Policy number Authorisation No: NICJPRO/2019 / G-129503 370200/46/11/8500000169

Reg: Important Note

Grant Date : 06/03/2012

To HEART & GENERAL HOSPITAL JAIPUR Hospital Code: - H-5437

With immediate effect all payment shall only be made through electronic transfer, hence you are requested to provide Bank Details along with "Copy of Cancelled Cheque" at Email ID kapil.kohli@parkmediclaim.co.in

Name of the Ins. Co. Insured Claimant Patient DOA Diagnosis

NATIONAL INSURANCE COMPANY LIMITED M/S RCDF FULI DEVI(RCDF-JP12/7/5065/Z307-D2) PRABHAT 05/03/2012 ACS, CAD WITH HTN

Guarantee of payment up to Rs. 3,012.00 (Rs. three thousand twelve) only towards the cost of necessary treatment. Hospital may please note that the amount exceeding a total of further authorization. Rs. 3,012.00 (Rs. three thousand twelve) only will require

EARLIER AUTHRIZATION FOR RS.9000/- STANDS WITH DRAWN.

Hospital must collect the excess amount over & above the authorisation amount from the concerned member prior to discharge from the hospital as per rules and regulations of the hospital. Hospial must collect the expenses on account of the following directly from the concerned member before discharge from the hospital : Registration fee, Admission charges, Misc. charges, Telephone expenses, Attendent's stay, Food, Washing charges, Private Nurse, Food supplements like Glucon D, Bournvita, Horlicks, etc, Toiletries like Soap, Shampoo, Oils etc, Perfumed antiseptic cream, Cosmetic treatment of Eyes / Teeth including their accessories, Water Purifiers and Energy drinks etc. and other expenses, which are not related to illness / treatment / hospitalization. Hospital may please note that final settlement of the cashless claim will be as per agreed upon Package/ Tariff rates, whichever is less. Hospital must submit following documents for the final settlement of the hospital bill to our office:1. Claim form of the NATIONAL INSURANCE COMPANY LIMITED duly signed by the concerned member 2. Final bill of the hospital in original (providing breakup of all expenses in corresponding heads / units / services) duly signed by the concerned member. 3. Photocopy of ID cards of Park Mediclaim Consultants Private Limited. 4. Original discharge summary. 5. All investigative reports, in original including all films of X-Rays / USG / MRI / CT scan etc. 6. Hospital must attach the sticker of IOL / IMPLANTS, if used in the surgical procedure. 7. Please provide details of your bank details i.e. Bank Name, A/c No, Branch and City.

For Park Mediclaim TPA Pvt. Ltd.

Authorised Signatory

Corporate Office :702, Vikrant Tower, Rajendra Place, New Delhi - 110008 Phone : 43191000 (30 LINES),25747454,25747455 Fax :41539390,43191004 e-mail :park@parkmediclaim.com Website : www.parkmediclaim.com