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    Vidal Agarwal

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    SJAIN12
    This document is a hospital visit form containing information about a patient's insurance, hospital details, medical history and proposed treatment plan. It includes the patient's name (Anil Kumar Jain), age (64 years old, male), insurance details, admitting hospital name and contact details, referring doctor's name, diagnoses of hypertension, unstable angina and atrial fibrillation, proposed 3 day hospital stay and ICU accommodation, and the doctor's signature.

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    Vidal Agarwal

    Uploaded by

    SJAIN12
    36 views2 pages
    This document is a hospital visit form containing information about a patient's insurance, hospital details, medical history and proposed treatment plan. It includes the patient's name (Anil Kumar Jain), age (64 years old, male), insurance details, admitting hospital name and contact details, referring doctor's name, diagnoses of hypertension, unstable angina and atrial fibrillation, proposed 3 day hospital stay and ICU accommodation, and the doctor's signature.

    Original Description:

    case no.1

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    This document is a hospital visit form containing information about a patient's insurance, hospital details, medical history and proposed treatment plan. It includes the patient's name (Anil Kumar Jain), age (64 years old, male), insurance details, admitting hospital name and contact details, referring doctor's name, diagnoses of hypertension, unstable angina and atrial fibrillation, proposed 3 day hospital stay and ICU accommodation, and the doctor's signature.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    36 views2 pages

    Vidal Agarwal

    Uploaded by

    SJAIN12
    This document is a hospital visit form containing information about a patient's insurance, hospital details, medical history and proposed treatment plan. It includes the patient's name (Anil Kumar Jain), age (64 years old, male), insurance details, admitting hospital name and contact details, referring doctor's name, diagnoses of hypertension, unstable angina and atrial fibrillation, proposed 3 day hospital stay and ICU accommodation, and the doctor's signature.

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    HOSPITAL VISIT FORM

    PRE- AUTH NO:


    1

    INSURANCE COMPANY

    POLICY NO

    VALIDITY

    TPA

    VIDAL HEALTH TPA P LTD

    TTK ID NO. OF PATIENT

    CLAIM NO

    KOL-UI-U0090-002-0010157-A
    KOL-0515-CL-0000124

    8
    9

    OTHER PROOF OF IDENTITY;Such as


    DL/Voter ID/Ration Card
    NAME OF HOSPITAL

    AGRAWAL HOSPITAL, BHOPAL

    10

    CONTACT NUMBER OF HOSPITAL

    11

    NUMBER BEDS

    12
    13

    IF REGISTERED -COPY OF
    REGISTRATION CERTIFICATE COPY TO
    BE ATTACHED
    PATIENT NAME

    14

    AGE & SEX

    15

    PATIENT CONTACT NUMBER

    16

    NAME OF THE CONSULTANT

    DR. AGRAWAL

    17

    PROVISION DIAGNOSIS

    HYPERTENSION , UNSTABLE ANGINA , ATRIAL


    FIBRILLATION

    18

    PRESENTING COMPLAINTS

    19

    DURATION -

    20

    21

    PAST HISTORY OF AILMENT:(IN CASE


    OF DM/HTN/IHD DATE OF FIRST
    CONSULTANCY- INCASE OF FATTY
    LIVER/CHORSIS OF
    LIVER/PANCREATISIS -ALCOHOLIC
    HISTORY)
    FINDING OF INVESTIGATIONS

    22

    PROPOSED TREATMENT

    23

    EXPECTED STAY AT HOSPITAL

    3 DAYS

    24

    DATE OF ADMISSION-TIME OF ADMN

    11/04/2015 AT 10.00 AM

    25

    13/04/2015 AT 06.00PM

    26

    EXPECTED DATE OF DISCHARGETIME OF DISCHARGE


    TYPE OF ACCOMODATION

    27

    CLASS OF ACCOMODATION

    ICU

    28

    ROOM RENT PER DAY

    29

    EXSPENSES AT THE TIME OF


    INVESTIGATION

    30
    31

    ANY OTHER INFORMATION


    REMARKS

    32

    CONCLUSION

    33

    FOR RTA

    34

    History of Accident

    35

    Alcoholic history

    36

    copy statement given by Patient


    Signature of the
    Patient/Representative
    SIGNATURE of the Doctor /Hospital
    staff with Hospital seal

    37
    38

    UI
    030400/28/15/P1/00597290

    ANIL KUMAR JAIN


    64, MALE

    ICU -1

    RS 34,615

    Signature of Investigator

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