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HOSPITAL TREATMENT CERTIFICATE
For Reimbursement Claim
Dear Sir / Madam,
It is requested to fill this form with complete & accurate details (as per your and hospital records - attach all attested relevant
case papers) to enable Birla Sun Life Insurance Company to process the claim in respect of the Life Insured expeditiously.
Details of the Hospital
Name of the hospital_____________________________________________ Hospital ID:__________________
Hospital Registration No with State Code:_______________ Type of hospital: Network Non network
Address of the hospital________________________________________________________________________________________
___________________________________________________________________________________________________________
PAN No:_____________No. of inpatient beds:__________
Facilities available in the hospital: OT : Yes No / ICU: Yes No
Other facilities available in the hospital
___________________________________________________________________________________________________________
Details of the Life Insured Admitted into the hospital
Name :_________________________________ Age:______Yrs IP Registration No.:______________
Date of admission:_________ Time:____Hrs____Mins: Date of Discharge:___________ Time____Hrs ____Mins
Status at discharge: Discharge to home Discharge to other hospital Deceased Discharge against medical
advice
Hospitalisation due to injury: Yes No If yes, give cause:
Pre authorisation obtained: Yes No NA If Yes, Pre Authorization No:___________________________
If no, give reasons:_______________________________
Name of the treating Doctor:_______________________ Qualifications / Specialty of the doctor:_________________________
Doctor’s Registration No with State Code _______________________ Phone No:___________________________________
Date of surgery, if any_____________ Name of the Surgeon:______________________ Phone No:___________________
Date of first consultation of the Life Insured for the present illness:____________
Describe the complaints/symptoms duration of the complaints/symptoms on the date of first consultation and admission
_____________________________________________________________________________________________________
What was the final diagnosis and when was the patient informed of the same. _______________________________________
___________________________________________________________________________________________________
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Please provide findings of the investigations made by the hospital supporting the diagnosis and prognosis (including results of
histopath (?), current x-rays, E.C.G., MRI or any other special tests with dates).
Types of tests conducted Date of the test Laboratory where the tests
were conducted
Findings
Has the Life Insured consulted any other physician/ health practioner for the above complaints? If yes please furnish the details
----------------------------------------------------------------------------------------------------------------------------- -------------------------------
Details to be furnished by the doctor who attended the Life Insured in regard to the current treatment
Are you the patient’s regular attending physician? : YES/ NO.
If Yes, since how long have you been acquainted with the deceased? ______________________________________________
When and for what illness/es did you treat the patient in the past? _________________________________________________
_____________________________________________________________________________________________________
Does the patient have any past health history? If yes, please specify those disorders/ illness and their duration
__________________________________________________________________________________
If yes, give details of previous consultation:
Dates of Consultation
/Hospitalization
Names of
Doctors/Hospitals
Nature Of Illness Diagnosis Treatment details
Is the Life Insured covered under any other Life insurance/ Health insurance/ Medi-claim/ Personal accident insurance with any other
Insurance company? If yes, give following details.
Name of the Insurance company Total Coverage Sum
Assured
Has any claim been lodged, in
connection with the present
disorder/illness (Yes/ No)
Benefits Received
(Yes / No)
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Certified that the above information is correct as per the records maintained by me/hospital and also as per the details given by the
patient / his…………………...( state the patient’s relationship to the person who has furnished the details ).
Name of the Doctor: ____________________________________________________________________________
Address: _______________________________________________________________________________
_____________________________________________________________________________________
Phone No.: _________________ Mobile No.:_______ Fax No No.: _______________________
Email ID:_____________________________________________
Seal of the Doctor Hospital: __________________________
Signed at ________________________________________this _________day of __________________20____________
Any confidential or other information relating to the patient , which you consider that the Company should know, may be
forwarded to the Claims Department at the below mentioned address:
Birla Sun Life Insurance Company Limited
6th Floor, Claims Dept., G-Corp Tech Park, Kasarvadvali, Ghodbunder Road, Thane (W)-400601.
Email:[email protected] Tel. no. 022- 39961000
Regd. Office: One Indiabulls Centre, Tower 1, 15th & 16
th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone
Road, Mumbai – 400 013. Website: www.birlasunlife.com Tel: 4356 9000
MD India Healthcare Services (TPA) Pvt Ltd
A2, 3rd floor, E Space, Vadgaon Sheri, Nagar Road, Pune,
