claim Acknowledgment Sheet Claim Document Check Claim Form.pdf claim form - part a' to 'claim form

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Name of Insurer : Policy No :Insured Name : Patient Name :PHS ID : Employee No :Mobile No : Phone (STD) :E-Mail ID : Type of Claim :Main Hospitalisation / Pre-Post Hospitalisation / OPD Claim / Deficiency Retrieval / Critical Illness / Cash BenefitSr. No DescriptionDocument Status Remarks1 IRDA Claim Form duly signed by the Insured2 Policy Copy3 64VB Compliance Certificate4Original Cancelled Cheque copy of Employee/Proposer with the name of the Account Holder Printed on the Cheque Leaf.5 Photo Identity & Address Proof of Insured (In case claim amount is 1 lac & above)6Original detailed Discharge Summary / Day care summary from the hospital in case of Day Care Treatment / Death Summary in Case of Death Claima) Copy of the Legal heir certificate, if the claim is for the death of the principle insured.b) Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006)[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]Plot no.A-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code 400 604CLAIM ACKNOWLEDGMENT SHEETCLAIM DOCUMENT CHECK LISTName of Corporate:b) Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)7 Original Final Hospital bill with breakup of each Item8 Original Payment Receipt of Main Hospital bill ( both Deposit / Refund)a) Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment Slip as received from the Vendor9Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/Mesh/IOL10 Original bills, original Payment Receipts and investigation / Laboratory Reports11Original medicine bills specifying Patient Name and date of purchase along with supporting Prescriptions.12 Original copy of First Consultation letter and subsequent Prescriptions.13In case of No / Delay Intimation & Delay in submission of claim, a letter from insured is required stating reason for the same14 OTHER DOCUMENTSaOriginal copy of Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. (Maternity Claim)b Original Sonography Report in case of Maternity ClaimcOriginal A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract ClaimdCopy of the First Information Report (FIR) from Police Department / Copy of the Medico-Legal Certificate (MLC) in case of Road Traffic Accident (RTA)eA medical certificate from a doctor not less qualified than MD/MS confirming the diagnosis of critical illness along with the Investigation reports/Other related documents reflecting the critical illness diagnosis. (Critical Illness Cases)fIn case of claims where the insured has submitted documents to another insurance co. /TPA, he needs to submit attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills and receipt for the same in originals.Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / HopsitalClaim Submitted by: Mobile No.Claim Submitted by: Mobile No.Date of Claim Submission: DD/MM/YYYY HH:MMPHS Executive Name:Claim Submitted at: PHS - (Location) / Help Desk Signature:Important Points to Remember:-6. Member is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. Documents once submitted will not returned unless approved & agreed by Insurer7. Corrections in any documents are not allowed5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App 3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will contact you on receipt of your claim documents by us2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk 1. Please mark either or against respective check boxCLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART ATO BE FILLED BY THE INSUREDThe issue of this Form is not to be taken as an admission of liablityDETAILS OF PRIMARY INSURED:a) Policy No.:(To be Filled in block letters)SECTION ASECTION Bb) Sl. No/ Certificate no.c) Company/ TPA ID No:e) Address:DETAILS OF INSURANCE HISTORY:a) Currently covered by any other Mediclaim / Health Insurance: b) Date of commencement of first Insurance without break:c) If yes, company name: Policy No.Sum insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract?Diagnosis: e) Previously covered by any other Mediclaim /Health insurance : :Date: M MYYYYf) If yes, company name:DETAILS OF INSURED PERSON HOSPITALIZED: :DETAILS OF HOSPITALIZATION: :DETAILS OF CLAIM:DETAILS OF BILLS ENCLOSED:Sl. No. Bill No. Date Issued by Towards Amount (Rs)DETAILS OF PRIMARY INSUREDS BANK ACCOUNT::SECTION CSECTION DSECTION ESECTION FSECTION GD YMD YM1.2.3.4.5.6.7.8.9.10.D YMD YMD YMD YMD YMD YMD YMD YMD YMD YMD YMD YMD YMD YMD YMD YMD YMD YMCity: State:Pin Code Phone No: Email ID:City: State:Pin Code Phone No: Email ID:D DD DM MM MY YY YYes NoYes NoYes Nod) Name: S U R N A M E F I R S T N A M E M I D D L E N A M Ea) Name: S U R N A M E F I R S T N A M E M I D D L E N A M Eb) Gender Male Female c) Age years M M Y Y Y YMonths d) Date of Birthe) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)(Please Specify)OtherRetiredStudentHome MakerSelf EmployedServicef) Occupationg) Address (if diffrent from above) :a) Name of Hospital where Admited:b) Room Category occupied: Day careD D M M Y Y H H H HM H M HD D M M Y Y Y YD D M M Y YSingle occupancy Twin sharing 3 or more beds per roomc) Hospitalization due to: Injury Illness Maternity d) Date of injury / Date Disease first detected /Date of Delivery:e) Date of Admission: f) Time g) Date of Discharge: h) Time: :NoYesI) If Medico legalj) System of Medicine:Substance Abuse / Alcohol ConsumptionI) If injury give cause: Self inflicted Road Traffic Accidentiii. MLC Report & Police FIR attachedii) Reported to Police NoYesa) Details of the Treatment expenses claimedI. Pre -hospitalization expenses iii. Post-hospitalization expenses v. Ambulance Charges:Rs.Rs.Rs.ii. Hospitalization expenses Rs.iv. Health-Check up cost:vi. Others (code):Rs.Rs.Rs.Totalvii. Pre -hospitalization period: days viii. Post -hospitalization period: daysb) Claim for Domiciliary Hospitalization: NoYes (If yes, provide details in annexure)c) Details of Lump sum / cash benefit claimed:i. Hospital Daily cash: Rs.Rs.Rs.iii. Critical Illness benefit:v. Pre/Post hospitalization Lump sum benefit:ii. Surgical Cash:iv. Convalescence:vi. Others:Rs.Rs.Rs.Rs.TotalClaim Documents Submitted - Check List:Claim form duly signedCopy of the claim intimation, if anyHospital Main BillHospital Break-up BillHospital Bill Payment ReceiptHospital Discharge SummaryPharmacy BillOperation Theater NotesECGDoctors request for investigationInvestigation Reports (Including CT/ MRI / USG / HPE)Doctors PrescriptionsOthersHospital main BillPharmacy BillsPost-hospitalization Bills: NosPre-hospitalization Bills: Nosa) PAN:c) Bank Name and Branch:d) Cheque / DD Payable details:b) Account Number:e) IFSC Code:(IMPORTANT: PLEASE TURN OVER)DECLARATION BY THE INSURED:I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppressionor concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA /Insurance Company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made.I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalizationclaim, if any.Date Y YD D M M Y Y Place: Signature of the InsuredGUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)DATA ELEMENT DESCRIPTION FORMATSECTION A - DETAILS OF PRIMARY INSUREDa) Policy No. Enter the policy number As allotted by the Insurance Companyb) Sl. No/ Certificate No.Enter the social Insurance number or the certificate number ofAs allotted by the oraganizationsocial health insurance schemec) Company TPA ID No. Enter the TPA ID No.Licence number as allotted by IRDA and printedin TPA documents.d) Name Enter the full name of the policyholder Surname, First name, Middle nameInclude Street, City and Pin codeEnter the full postal addresse) AddressSECTION B -DETAILS OF INSURANCE HISTORYa) Currently covered by any other Mediclaim / Health Insurance?Indicate whether currently covered by another Mediclaim /Health InsuranceTick Yes or Nob) Date of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmatc) Company Name Enter the full name of the Insurance Company Name of the organization in fullPolicy No. Enter the policy number As allotted by the Insurance CompanyIn rupeesEnter the total sum insured as per the policySum insuredd) Have you been Hospitalized in the last four years since Inception of the contract? Indicate whether hospitalized in the last four years Tick Yes or NoDate Enter the date of Hospitalization Use mm-yy formatDiagnosis Enter the diagnosis details Open TextTick Yes or Noe) Previously covered by any other Mediclaim / Health Insurance?Indicate whether previously covered by another mediclaim / Health Insurancef) Company Name Enter the full name of the Insurance Company Name of the organization in fullSECTION C -DETAILS OF INSURED PERSON HOSPITALIZEDa) Name Enter the full name of the patient Surname, First name, Middle nameb) Gender Indicate Gender of the patient Tick Male or Femalec) Age Enter age of the patient Number of years and monthsd) Date of Birth Enter Date of Birth of patient Use dd-mm-yy formate) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option, if others, please specifyf) Occupation indicate occupation of patient Tick the right option. If others, please specify.g) Address Enter the full postal address Include Street, City and Pin codeInclude STD code with telephone numberComplete e-mail addressh) Phone No1) E-mail IDEnter the phone number of patientEnter e-mail address of patientSECTION D - DETAILS OF HOSPITALIZATIONa) Name of Hospital where admited Enter the name of hospital Name of hospital in fullTick the right optionTick the right optionUse dd-mm-yy formatUse dd-mm-yy formatUse hh-mm- formatUse dd-mm-yy formatUse hh-mm- formatTick the right optionTick Yes or NoTick Yes or NoTick Yes or NoOpen Textb) Room category occupiedc) Hospitalization due tod) Date of injury/Date Disease first detected / Date of Deliverye) Date of admissionf) Timeg) Date of dischargeh) TimeI) If injury give cause If Medico legalReported to PoliceMLC Report & Police FIR attachedj) System of Mediceneindicate the room category occupiedindicate reason of hospitalizationEnter the relevant dateEnter date of admissionEnter time of admissionEnter date of dischargeEnter time of dischargeindicate cause of injuryindicate whether injury is medico legalindicate whether police report was filedindicate whether MLC report and Police FIR attachedEnter the system of medicine followed in treating the patientSECTION E - DETAILS OF CLAIMa) Details of Treatment Expencesb) Claim for Domiciliary Hospitalizationc) Details of Lump sum/ Cash benifit claimedd) Claim documents Submitted-Check ListEnter the amount claimed as treatment expencesindicate whether claim is for domiciliary hospitalizationEnter the amount claimed as lump sum / cash benefitindicate which supporting documents are submittedTick Yes or NoTick the right optionIn rupees (Do not enter paise values)In rupees (Do not enter paise values)SECTION F - DETAILS OF BILLS ENCLOSEDIndicate which bills are enclosed with the amount in rupeesSECTION G - DETAILS OF PRIMARY INSUREDs BANK ACCOUNTa) PANb) Account Numberc) Bank Name and Branchc) Cheque/ DD payable detailsc) IFSC CodeEnter the permanent account numberEnter the Bank account numberEnter the Bank name along with the branchEnter the name of the beneficiary the cheque / DD should bemade out toEnter the IFSC code of the Bank branchAs allotted by the Income Tax DepartmentAs allotted by the BankName of the Bank in fullName of the individual / organization in fullIFSC code of the Bank branch in fullSECTION H - DECLARATION BY THE INSUREDRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.SECTION HCLAIM FORM - PART BTO BE FILLED IN BY THE HOSPITALThe issue of this Form is not to be taken as an admission of liabilityPlease include the original preauthorization request form in lieu of PART A(To be Filled in block letters)DETAILS OF HOSPITALa) Name of the hospital:a) Hospital ID:c) Name of the treating doctor:e) Qualification:DETAILS OF THE PATIENT ADMITTEDc) Type of Hospital: Network : Non Network : (if non network fill section E)f) Registration No. with State Code: g) Phone No.a) Name of the Patient:b) IP Registration Number: c) Gender: Male Female d) Age: Years Months e) Date of birth:ii) Gravida Status: :m) Total claimed amounth) Date of Discharge:i) Date of Delivery: k) If MaternityMaternityDay CarePlannedEmergencyf) Date of Admission:j) Type of Admission:I) Status at time of discharge: Discharge to home Discharge to another hospital DeceasedDETAILS OF AILMENT DIAGNOSED (PRIMARY)a) ICD 10 CodesI. Primary Diagnosis ii. Additional Diagnosis:iii. Co-morbidities:iv. Co-morbidities:vi. If not reported to police give reason:Description b) i. Procedure 1:ii. Procedure 2:iii. Procedure 3:iv. Details of Procedure:ICD 10 PCS Descriptionc) Pre-authorization obtained: YesYesYes YesNoNoNo Nod) Pre-authorization Number:e) If authorization by network hospital not obtained, give reason: f) Hospitalization due to injury: I. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumptioniv. Reported to Policeiii. If Medico legal:(If Yes, attach reports)ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this:v. FIR No.CLAIM DOCUMENTS SUBMITTED - CHECK LISTClaim Form duly signedOriginal Pre-authorization requestCopy of the Pre-authorization approval letterCopy of Photo ID Card of patient Verified by hospitalHospital Discharge summaryOperation Theatre NotesHospital main billHospital break-up billInvestigation reportsCT/MR/USG/HPE investigation reportsDoctors reference slip for investigationECGPharmacy billsMLC reports & Police FIROriginal death summary from hospital where applicableAny other, please specifyADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)(PLEASE READ VERY CAREFULLY)a) Address of the Hospitald) Hospital PAN:iii. Others:DECLARATION BY THE HOSPITALWe 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:Place: Signature and Seal of the Hospital Authority:SECTION ASECTION BSECTION CSECTION DSECTION ESECTION FYes NoYes NoCity: State:Pin Code: b) Phone No. c) Registration No. with State Code:e) Number of inpatient beds f) Facilities available in the hospital i. OT ii. ICU Yes NoS U R N A M E F I R S T N A M E M I D D L E N A M ES U R N A M E F I R S T N A M E M I D D L E N A M ED D M M Y Y H H M MY Y M MM MM MD DD DH MH MYYD D M M Y YD D M M Y YYYg) Time: GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)DATA ELEMENT DESCRIPTION FORMATa) Name of the hospital:b) Hospital IDc) Type of Hospitalc) Name of treating doctorSECTION A - DETAILS OF HOSPITALe) Qualificationf) Registration No. with State Codeg) Phone No.Enter the name of hospitalEnter ID number of hospitalIndicate whether in network or non network hospitalEnter the name of the treating doctorEnter the qualification of the treating doctorEnter the registration number of the doctor along with the state codeEnter the phone number of doctorSECTION B - DETAILS OF THE PATIENT ADMITTEDa) Name of Patientb) IP registration Numberc) Genderd) Agee) Date of Birthf) Date of Admissiong) Timeh) Date of Dischargei) Timej) Type of Admissionk) If MaternityDate of DeliveryGravida Statusl) Status at time of dischargeM) Total claimed amountEnter the name of patientEnter insurance provider registration numberIndicate Gender of the patientEnter age of the patientEnter date of birthEnter date of admissionEnter Time of admissionEnter date of DischargeEnter time of DischargeIndicate type of admission of patientEnter Date of Delivery if maternityEnter Gravida status if maternityIndicate status of patient at time of dischargeIndicate the total claimed amountSECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)a) ICD 10 CodePrimary DiagnosisAdditional DiagnosisCo-morbiditiesb) ICD 10 PCSProcedure 1Procedure 2Procedure 3Details of Procedurec) Pre-authorization obtainedd) Pre-authorization Numbere) If authorization by network hospital not obtained, give reasonf) Hospitalization due to injuryCauseIf injury due to substance abuse/alcohol consumption test conducted to establish thisMedico LegalReported to PoliceFIR No.If not reported to police, give reasonIndicate which supporting documents are submittedSECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LISTSECTION E - DETAILS IN CASE OF NON NETWORK HOSPITALa) Addressb) Phone No.c) Registration No. with State Coded) Hospital PANe) Number of Inpatient bedsf) Facilities available in the hospitalRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. and stampEnter the ICD 10 Code and description of the primary diagnosisEnter the ICD 10 Code and description of the additional diagnosisEnter the ICD 10 Code and description of the Co-morbiditiesEnter the ICD 10 Code and description of the first procedureEnter the ICD 10 Code and description of the second procedureEnter the ICD 10 Code and description of the third procedureEnter the details of the procedureEnter pre-authorization numberIndicate whether pre-authorization obtainedEnter reason for not obtaining pre-authorization numberIndicate if hospitalization is due to injuryIndicate cause of injuryIndicate whether test conductedIndicate whether injury is medico legalIndicate whether police report was filedEnter first information report numberEnter reason for not reporting to policeEnter the full postal addressEnter the phone number of hospitalEnter the permanent account numberEnter the number of inpatient bedsIndicate facilities available in the hospitalSECTION F - DECLARATION BY THE HOSPITALName of the hospital in fullAs allocated by the TPATick the right optionName of doctor in fullAbbreviations of educational qualificationsAs allocated by the Medical Council of IndiaInclude STD code with telephone numberName of patient in fullAs allotted by the insurance providerTick Male or FemaleNumber of years and monthsUse dd-mm-yy formatUse dd-mm-yy formatUse hh:mm formatUse dd-mm-yy formatUse hh:mm formatTick the right optionUse dd-mm-yy formatUse standard formatTick the right optionIn rupees (Do not enter paise values)Include Street, City and Pin CodeInclude STD code with telephone numberAs allocated by the City Corporation / MunicipalityAs allocated by the Income Tax DepartmentDigitsTick the right option. If others, please specifyStandard Format and Open textStandard Format and Open textStandard Format and Open textStandard Format and Open textStandard Format and Open textStandard Format and Open textOpen textTick Yes or NoAs allotted by TPAOpen textTick Yes or NoTick Yes or NoTick the right optionTick Yes or NoTick Yes or NoAs issued by police authritiesOpen textEnter the registration number of the Hospital obtained from local bodylike City Corporation / Municipality

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