PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED

Authorization letter to the Hospital for treatment and guarantee of payment

Valid for admission between 28/07/2017 and 12/08/2017 dates
To,
KOTHARI MEDICAL CENTRE
8/3, Ailpore Road,
CCN No.: 3585097 EXT.:
Kolkata
(Please Quote This CCN in all future correspondence)
Kolkata 700027
Fax No. (033)24567044 / 24567171
WE HEREBY AUTHORIZE YOU TO ADMIT THE FOLLOWING PATIENT:
NAME OF THE PATIENT: RAVI PARAMOUNT HEALTH ID NO: NA KOL 24640151 IIOMC E

NATURE OF ILLNESS: # Bimalleolar Lt Ankle

APPROVED MAXIMUM LENGTH OF STAY(LOS)(DAYS): 5 CLASS OF ACCOMODATION: SPL BED

GUARANTEE PAYMENT UPTO Rs. 20000 (IN WORDS) RUPEES TWENTY THOUSAND AND ZERO PAISE

Special Remarks: SERVICE SURCHARGE ADM REG & NON MEDICAL EXP NOT PAYABLE.
ALL CHARGES WILL BE PAYABLE AS PER AGREED TARIFF BETWEEN PHS & HOSPITAL.
PROVIDE FINAL BILL & DISCHARGE SUMMARY.

Important Note:

NOTE:
If the hospital bill is estimated to be higher than the guarantee of payment, and or LOS will be longer than authorized request
letter for additional amount and/or days needs to be sent to Paramount Health for review.
If no further guarantee is available, the hospital must collect the excess amount directly from the beneficiary at the time of
admission / prior to Discharge from the Hospital, as per Hospital Rules and Regulations
Please send the following within 7 days of discharge of the the beneficiary :
Hospital bill summary, detailed final bill of each services along with xerox copies of indoor case papers, dualy attested and
paginated. (Authenticated by the patient's signature)
Detailed Discharge summary / card and reports of all investigations ( Original ), prescription of medicines and the
insurance claim form of NATIONAL INSURANCE COMPANY LTD. signed by the Patient / Beneficiary
PHS is not liable to make any payment if the claim file along with all the necessary and relevant documents are not
received within a period of 7 days from the date of discharge of the insured

( PANCHALI SENGUPTA (DR.) )

Authorized signatory Stamp AL No.: 2180628 Date : 31/07/2017
Please Note that Hospitalisation for Treatment of following conditions is not Payable :
1) Convalescence,General Debility,"Run Down" condition, Rest Cure, Congental External Diseases, Sterility, STD, intentional
self-injury and use of alcohol/Intoxicating drugs.
2) Paramount will not be held liable for the payment in the event of any discrepancy between the facts presented at the time of
admission & in final document submission.
TDS:- All payments to hospitals are subject to deduction of tax at source as per prevailing rate under section 194J of Income Tax
Act unless lower /nil TDS certificate had been provided to the payer under section 197 of Income Tax Act ,1961.
Service Tax : Service Tax is not applicable on or after 01.05.2011 as per Ministry of Finance Notification No. 30/2011 -Service Tax
dt.25.04.2011
Disclaimer : The cashless access in PHM network of hospitals is merely a facility extended by your health coverage payer.
Paramount Health / Payer does not guarantee the availability, quality and outcome of the treatment. Choosing of
a network or a non-network hospital is a prerogative of the beneficiary.
Undertaking by the Patient / Insured
I authorize the Hospital / Provider to submit the original discharge card, and all original documents related to my treatment to
Paramount Health which will ensure timely payment to the hospital.

Rohini Instruction -
We have noticed that your ROHINI registration status is not complete for your hospital. We request you to complete your
registration status on ROHINI portal before the release of the payment.
Signature of the Patient / Beneficiary