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REQUEST FOR CASHLESS HOSPI TALISATION FOR MEDICAL INSURANCE POLICY

tvlfifi A$f,iilI

P r -t AL
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a)Nameof TPA: Medi Assist Insurance TPA PVt Ltd b)TollFree PhoneNurnben lBAQ 425 9449 t) Ioll !fce F AX !l')':rL

To Be filled in Bv Insured / Patient

a)NameorthePatien' j-"j' lb ..giloliilIflFli---i :L ll- .i lt..l j\rlili-g h.'
'S.
b) Gendor: l.l tvtale :-ffiiur" c)nge, vearsffi@l Monthsi -. (i) Date ot l)il th
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e) Contactnumber:
il i,q iqt iql I lqt loI
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QlnsuredCardlDNunrUe',
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g)Policynumbcr/Nameofcorporate:
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h) iriploye.:lD -t o o h69ll
h)Cuffently doyou have anyother l4ediclainvHealthlnsurance: i i Ves
V*" CompanyNar]re
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ttve oetart5:
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rJiloyoLlraveifamilyphysrcian :- Ye5 ,..1;Xo j)Nameofthefamrlyphys(ian. ., a
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k)co,rtacrnu,nbeiifanyr
. IL-JllL-I llL_JI llflTlflfln
L_J I---I LJ LJ L-J I-I ltt
TO BE FILLED BY THE TREATING DOCTOR / HOSPI TAI-

a) Name of the treatingdoctor

iD;l{i iv:ik-li6iiu-iiP-llt ini l ii li'"Dbt$3.1
t. .,.... b)(onla(1Nlrrrrre, Q Staoo-lehV
;i li ;r l. .r ,

c) NameoflLLNESS /Disease
with presentinst complaint5 I ?Airt",+ 9uSOt".fq- ft"J a;n"i.uunt clinicalnndinss, (6erir.r-t
HreD SeyLfZ€ VtP{rtrc
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,
f) f'tclvisionaldiarlnosis; I :ailmentfanyl

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g) Propased lineof
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J.V/ tueaicat Management Man"n.;;;r;
treatment: {--.] surgicat 1,/ tr,r",.tiu".urr,' L/rn,r?si,qi,r,or\ ri,:ir.rl
-, -
h),f investigation,, orMedical
X- g$n- GC.gi'\tJRoure()rcrusdomrnr:;trdtro'|r
Management provide
details:
MP-.1 bp4nN
fltoe D \r.lv ex1\ (irarto rv.
Jt P+$"(t 4 DU>r €ou"rL
i) lf Surgrcal.namoof 5urgery:

i. lcti I0t!1.; ( ocle

:

j) lfother treatments provide i (r llow dlcj iliitty ai.tr

details i i

l) f n case of

v; Injury,/Oisease
accidenl t. ts it tiTA: i ) Vu l\X{
causeddueto substanceabuse/alcohol consumption:
ii. Dateof injury:

i i yes vi.Tertcorrjucte(l t,i

,ii.

eltablishthisi , "*r
fieported to Folicr.

No ilf re5
#- l! Flil f\.!at

nr)in.ise of Mat:lnity: C t -.*_j t

_- .:- _ _,
Dai.oiDeirvery/ l-Mp
Details of the parient admitecl

;1i,, o ti
Manciatofy:

*.li'l'.gi eO
Dareoradn,;s5ion,
a)
/
b)Time
, i,'q Past llistorl of ary.hfo.klllne!{ tf yes, qin.,

() i5 tl':san cmLr{Jcncy/a pldn,rc'd hospitalr?ationcvcn f. Diabete:

\r/ Ea"rg"n.u .,
plarrned

tf Heart Dise'r:r
d)expectedno.of daysstayinhospitat: ,l j *r, e) RoomType lC U + QOI Roo*l
,o6^. uypertens'on
I
0perDayRoomRenuNursins&servicecharses+patientsDieti ns. tt j[-i id_i
lok i] . Hyperlipi(iefni.rs
investigation+diasnostics: f
s) Expectedcost for Rs. i?l
iO,f 6"] itPi- i iF O5teoirrthriti5
charees:
:

h)rcu Rs. g i y lJf ioh ii * Asthma/COPD/Bron<hirls

i)orcharses: Rs, i. i_.1 i" l i , l 'l .'7E Cancer
-j
j) pforessionalfee5 s!'rgeon+AnesthetistFees charges: Rs. t,'
tt fj i.o iio fr-'
+ consurtation j
i Alr:oholor c-rr,ig alrr::+

k)Medr(in..s+Con5umables Costoftmplanri(ifapplrcableplear" - '' n i

Rs 'Ol- ArrVrllV or sTD , Relirred.llrllenls
speclr)..otherrosr.ltarexpen:erifany: Q g:o |i
Atly arliter,r.,it ii,,..,rl (j,,i !lrtt.jrt
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l, Ai{ ;'rclusivcpa(kJ9c charge5rfanyapplicable: F:. : -
.,

rn)sun)rotarexpectedcosrolrospitarizatio,, Rs. g;rtln

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DECLAR ATION

We confirm having read understood and agreed to the Declaration on the reverse of this form

a) Nimeortherre,ri,,e croctor: i : I 0iiU i_pii fl {A]i:i,i t il li ii ii ii :lt I i:i i'iDRVK

brQualihcation: iHidi-t{-i ii.--]i-, il ltr*tistrationNo.withstatecode: 8:i 8,,41'.1". i ii
Hospital Seal (Must incl ude Hospital lD) et.*.qtdww PatienL/lnsuredNdn)e & Signatufe:

N,159, i I M PQBI ANLPIEA5E LU-8 N,pt{qB

 e-nPt'yutor- Tosh6Qh

|[[dll], fu*: t* iii rr,,{rri}riilr.irii i;

DECTARATION BYTHE PATIENT / REPRESENTATIVE

before my discharge.

conditions of the policy.

'#if:#'$:f:,"ff
4.|herebydec|aretoabidebythetermsandcondjtionsofthepo|icyandifatanyfactsdisc|osedby
the insurer / T.P.A.

particular quality or standard.

to lhe claim, my right to claim reimbursement of the said expenses

shall be ibsolutely forfeited.

/' I agree to indemni[i the hospital against all expenses incurred on my behalf, whtch are
nol reimbursed by the insurer / TpA.

a) Patienl's I Insured's Name

l,y contactllumner: 7h I 9Q4 l? C4 c) Patient's / Insured's Signature

q tl

d) Contact Number ot Ot,und,nn *r,r,'u,

HOSPITAL DECLARATION

'l We have no objection to any authorized TPA / Insurance Company official verifying
documents perlaing t0 hospitalizaiion

2 All valid original documenis duly countersigned by the insured / patient as per the checklist below wilt be senl rpA I Insurance Company wiihin / days of ihe patrenr s discharqe

2 non medical expenses, 0R expenses not relevant to hospitalization or illness,

.All OR expenses disallowed in the Authorization Letter of the TpA I Insltranii-. Cl. 0R arsin; oitl
information in the pre-authorisation form will be collected from the
oatient.

4' WE AGREE THAT TPA / INSURANCE COMPANY WLL NOT BE LIABLE TO

AND DISCHARGE SUI\4MARY or other documents.
MAKE THE PAYMENT IN THE EVENT OF ANY DISCREPANCY BETWEIN I iI: F:A|.I

5. The patient declaration has been signed by the patient or by his represent
in our presence.

6 we agree provide clarification for the queries raised regarding this

hospitalization and we take the sole responsibility for any delay rn otlenng clariflcaiions.

7. We will abide by the lerms and conditions agreed in the MOU.

flospital Seal
Doctor's Signaiure

d. *. qt-+un Esdm
N-159, qrge zrFr,
q;{.d.sTri.s\ vrsi,

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF

THE CLAIM

1. Detailed Discharge Summary and all Bills from the hospital.

2. Cash Memos from the Hospitals / Chemists supported by proper prescription.

3 Receipts and Pathological Test Reports from Pathologists, supported by

note from the attending Medical practitioner / Surgeon facommendinc such p:l|1 ,lr il
4. surgeon's certificate stating nature of operation performed and surgeon's
Bill and Receipt.

5. cerliucates from attending Medical practitioner / surgeon that the patient

is fullv cured.
 Cnlbve
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ThiscardisonlvforidentificatiSnancjisrlotanauthorizahont.ip{''oijldl r'!i
lhe treatment oi a guarantee for payment.
ln the case of Dhotoles$ identrtv cards issued to berlet,cra'res, ac(eiJlar"'
of identitv such as Aadhar Card/PassporVDriver Llccnse/ Ralioil Cattd I r ',lr"t ,
lD Carcl / PAN Card $hould be pfe$ented al hospilals

f******- ---***l This non-lransferable identificaiion card is vaiid ai selecied lrlotwork l'losl i:rirr
jirrrlifiii!iiv te;rn Gaur;tv Kumar I ,li,jr, ':ir,.!.r r.
:
& will enable Card Holder to avail oashless hospitahza(ioil ofily ci) lhe bar,rii r1
preauthorization by Medi Assist.
lri,f1]il,x,i,1. fr*3t3'? 33't 5t i j:;;.i:.:; ,
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For the latesl updated Netlvork holipital iisl, logln lo ww'r'' nre.jiluilriv.rrr
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Tower D,4th Floor, IBC Knowledge Park,4/1, Bannerghatla Road, i\ lvl ra);oul. iii;.{',1., ,
''''''''.'''''''.''.'. Karnataka 560029.C1N: U851 99KA1 999PTC025676
1.jrtt: *i irifii; 1$ JEsi -l99*
6 s@ Website: www.medibuddy.in Email: no{eply@mediassistindla,conl
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Contact number: 18004198541

. ;;;;'; ;;;;;;;;"^ un.r i, noL on au,r,o'zrt'o,! t(r p,i,ceec w i,

";;;;;.
lhe treatment oi a guarantee for paymenl.
. In the case of ohotoless identitv cards issued to bettefrcrafies, acc€'piabi.l t).i
of identitv such as Aadhar Card/Passporl/Driver Licolrs(r/ R?llion Carcj I i.iii.'
lD Card / PAN Card should be oreseited at hospitals. "
. This non-transferable identificaiion card is valid at selricled l'.letwork l-iDsr,': i'
&{l:kt:r*h l}r;vf & will enable Card Holder lo avail cashless hospitalr:13liorr o.)iy irr tilii ir r' i
preauthorization by Medi Assist.
l,.4f,ill.1itf li:. s*3{J''3}r ** Forthe lalestupdated Network hospitai iist logitr lc *r"r. irr',:ii:)'j{l(:, '

li-trrplily{ie tiir.i{jl ?*{r4**4 lfl*#i &S$1$? tldi;*'tAliilil i i]i; Ffil'r: I I rir,', ': ,.'
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Tower D, 4th Floor, IBC Knowledge Park. 4/1. Bannefghtta Rcacj, ( [/.Layo!1. ddngrl
*.::i: if ilirliil {iJ Ja$ tS++ Ka.nataka 560029.C1N: U851 99KA1 999P l.C02ltii'6
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Gontact number: 18004198541
 .,t
Enptoyu €or _ 7oo46 q q

Address:
S/O: Jiteirdra Singh, Shapti nagar
, kukda, Kukra, Muzaffarnagar,
Muzaffarfi agar, Uttar Pradesh,
51312015 IMG-201 90503-WA0005 1p9

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 genitieu
Lnftry[0j'r0o 1(l'1 |10 ffi fifff
Shivam Diagnostic C:entre** rRulr
10,*ulil Dlilts0ti0 [0[|tru t|litll l0ital 0l 0[0llt fflltll[[|t'l '*""0"0
ilABll
GENTIfIEII Mob. : 9896549901, 8607888996, 01662245479
HOSPITA1

PATIENT'S NAME: MUKESII DEVI/I 30955 AGE/SEXI 45Y lF

REFERRED BY:-DR.V.K.GUPTA DAT8.03.05.2019

o The bone density appears normal.

o Cervical lordosis is lost.

o IVD space appears normal.

. F"y marginal osteophytes at anterior cervical level from c4 to c6 levet.

. Spinous processes look normal.

o Pre &Paravertebral soft tissue look normal. .

IMPRESSION:

Report with thanks,

DR.MOIIANLAL GARG
M.B.B.S.,M.D.
(RADTO DTAGNOSTS)

ln Pursuit of excellence in radiology

ffir]iilfr ffiru-roron oopprrn. urrnnsouND . DrcrrAL X'RAY 'NGV " EMG 'EEG 'EGG
CLlNlcAt & tAB0RAT0BY C0BREIAT|0N.
 €rtPAYc, An: - 70 o4t eh

(A Unit of VKHMD

NABH
CERTIFIED
HOSPTTAL
Mob. : 9896549901, 8602888996, 01662245479

NAME : MUKBSII DEVr/4o955 REF. BY: - DR.V.K.GUPTA

SEX/AGE: -F/+sy
EXAMINATION:-MRT BRAIN
DATE: o2.o5.2o19
MRI is performed with sequential axial Trw,
Tzw, FLAIR , DW & coRoNAL images.
MR study reveals:-

Bilateral cerebral hemispheres show normal

morphology and signal intensity pattern.
Bilateral basal ganglia & thalam,i appear to
be normal.
Cerebellum and brainstem appear to be normal.

No evidence of any extra-axiar coilection

or intra-axial haematoma seen.
No evidence of anymass lesion.

No evidence of midline shift seen.

Bilateral hippocampi appear normar in size

and signar intensitypattern.
Allparanasal sinuses are clear.
IMPRESSION..-

CHANGES IS SEEN.

M.B.B.S., M.D
(RAD|O DIAGNOStS)
DR V K GUPTA

In pursuit of excellence in radiology

' MRI' SPIRALC.T.SCAIII' G0L0B EOPPIEB . ULTRAS0UND . DlclTAtX.BAY . NGV . EMG . EEG . EGG
THIS IS A PROFESSIONAL OPINION NOT A FINAL DIAGNOSIS. IT NEEDS CLINICAT & TABORATORY CORRETATION.
 Patient Name : MRS. MUKESH
DDVI
Age ; 45 years (Female)
Referral : V.K GUpTA
Reg. ID :ALVK-16
Report Date : May 02,2019,03:09
p.m.
Report lD :37O22
Sarnple Date : May 02,20Ig,02:32
p.nt,
Sample ID : 191220058

COMPLETE FI'ooP couNT

Test Description Value(s)
varuels, Unit
Unit Reference Range
RED BLOOD CELLS
HEMATOCRIT 9.61 mil/mm3 3.8 _ 4.8
MCV 26'5 To 3T - 47
MCFI
7e.4 fL 80-96
MCHC
2t.3 pg 27 -3A
29.7
RDW.CV c/dl 30-35
PLATELET COUNT
19.O % 11.5 - 15
MEA]\ PLATELET VOLUME
349000 thou/cumm 1SOOOO _ 45O0OO
TLC
9.9 fl 6.5 _ 12.O
8200
4000_ 11000
WBC DIFFERENTIAL COUNT
IVEUTROPHILS
65.2
LYMPI-IOCYTES % 40-80
23.6 ,r/o
MONOCYTES 20-40
6.72
BOSINOPHILS % 2-70
4.48
BASOPHILS % 1-6
0 ok
o-2
ABSOLUTE LEUCOCYTE COUNT
A NEUTROPHILS
J.JJ thou/mm3
A I,YMPHOCYTES 2.OO - 7.oo
1.94 thou/mm3
A MONOCYTES 0.80 - 4.00
u.55 thou/mm3
A EOSINOPHILS o.72 - 7.20
o.37 thou/mm3
A BASOPHILS 0.02 - 0.50
0 thou/mm3
PERIPHERAL SMEAR STUDY 0.00 - 0.10
RBC MORPHOLOGY
Microcytic Hypochromic
WBC MORPI_IOLOGY
Adecluate
PLATELETS
Adequate
MALARIA PARASITtrS
Not Seen
METFIOD
F-ULLY AUTOMATED BC-3600

**ENI) OF REPORT*"

iir.il:
-
I)r. Slrreta Eansnl
IlD Palhdlogr-

CONSULTANT
(Pathotogisr)
H
 *loo461I

Patient Name : IVIRS. MUKESH DEVI

Age : 45 years (Fernale)
Referral : V.K GUpTA
Reg. ID :ALVK-16
Report Date ; May 02,20ir9, O3:OB p.m.
Report ID :37020
Sample Date : May 02,20Ig, 02:32 p.rn
Sample ID : 191220058

Lrqrq PROFTLq
A**::T::i- varue(s) unit Reference Range
StrRUM TRIGYCERTDtr 145.98 mg/dl 60 _ \Zo
SITRUM HDL CHOL1ISTEROL
4r.o mg/dr sS iS"
StrRUM VT.DL CHor_trSTROL
2g.2 mg;/dt ,; ;;
StrRuM LDL CHOLESTRoL
r26.ss mg/dl ; - ;.
SERUM ToTAL/HDL Cr{or_ESTERor.
4.8\ ,"i,o ;; ;;
StrRUMLDL/HDL 3.1 .;;;;
NON-I-IDI- Chotesterol Serum
;;_;:
1S6.tS mg/dt ;;, ;;.
f Method : Erlzymatic Colgrimetric.)

Note:
1 In this i'ipid Profi1e Total scrum cholcsterol
rriglycericles ancl HDL are measured components.
if Serum Triglyceride s le'els are high thcn Friedcwald
equation does not hord true and a
q measured
lrrLao ul cLt LDL test is
advised
3' wo I-IDI- (Good cholesterol) is benelicial while increase in LDL (Bad cholesterol)
is an indicator of high.
-&ctor.
-r. !TOI- is by homogenous Enz.vmatic (jolorimetric
method.
5 VLDL, LDL & Ratios are calculated parameters.
utolo"*]cal R1lrence range lbr Total cholesterol-Desirable
,u;, , <200 mg/dl, Border iine: 2oo -239 mg/dt, y
tr{igh: >240ra'ALTriglyecrides-Desirable <
150 mg/dl,Boderline: i50-1gg mg/dl,VHigh:>500
HDl-Desirable: > 60 mg/dl. High Ri < 40,0mg/di. mgldl,
LDl-Desirable < 1oo mg/dl High Risk: 130 -159 mgldl,
Fligh: > 190 rng/cll, Non - IIDL chotesterol is V
Desirable < 130 mg/dl,High: 160 -1s9 mg/di. VHigh: >
ms /r11 190

Serum Creatinine
o.B7 rno / dl
(Modi{ied Jaffe) u.D - 1.5

URIC ACID, StrRUM

3.4 5
(iJRrcASE _ PAP) 2.4"- 5.7

CONSUTTANT
(Pathologisr)
 &/A7ulo> Too \n c1

RHEUM.ATOLD F$CTOR {RA}.SERUM

RHtrUMATOID FACTOR (RA),SERUM NEGATIVE NEGATIVE
NOTE
Gives useful objective evidence of RA, but a negative test does not rule out RA. Negative in a third of patients
with definite RA. Positive result in < 5O%o cluring first 6 months of disease. Sensitivity : SO - T5o/o; Specificity :

75 - 90%.

*NEND OF REPORT**

f:$ _
Ir.. Sh\etn B.nstl
IID Prthology

C()NSUI.TANT
(Pathologisr)
Page 2 of 2
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