Scribd Logo
Upload

Welcome to Scribd!

  • 86 views

    CL 004125571

    Uploaded by

    Lokesh Kuppili

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd

    CL 004125571

    Uploaded by

    Lokesh Kuppili
    86 views12 pages

    Original Title

    CL-004125571

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    86 views12 pages

    CL 004125571

    Uploaded by

    Lokesh Kuppili

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    You are on page 1of 12
    | | File Received Date: 06/12/2018 | WA leer hig) No. of Documents IHEALTH CARE Documents Received From: fal / [DNF -]_ NEFI Platinum TPD PHOTO | | pop sNott=f 2-frop No HS Us TY & Inward Date: - -DEC-2018 Inward Date & No CL-00 Ul2s5H Patient Name satue, Ra a Policy Name Mol) Se veo Policy Classification Retail / Compare _/_Mass ‘Type of Document Network Reimbursement __/_Member Reimbursement Main Qian 7 Pre-Post 1 Addendum’ OPD / Query Type of Cla spon: RAJU Py Inward Exce: X RAY FILM IMPLANT STICKER: IMPLANT STICKER. sox{ | World Health “Organization Date ; 03.12.2018 To ICICI Lombard GIC ICICI Lombard Health Care ICICI Bank Tower, Plot No: 12 Financial District, Nanakram Guda Gachibowli, Hyderabad - 500 032 , Telangana Dear Sir, Sub : Submission of Medical Bill. Reg. Ref: AL No: 110209827684 UHID No: 1L13624683404, Dt: 27.11.2018. Herewith we are submitting Medical Bill in the Name of Mr K Satya Rao along with your Authorisation Letter of Rs.19,300/-(Rupees Nineteen Thousand and Three Hundred Only) for Payment at the earliest. if coUlLsS H The Draft/Cheque may please be issue in favour of HYDERABAD EYE INSTITUTE, payable at VISAKHAPATNAM. and sent it to L.V. Prasad Eye Institute, G.M. R.Varalakshmi Campus, D.No. 11-113/1, Hanumanthawaka Juction, VISAKHAPATNAM - 530 040. Kindly acknowledge the receipt for the same. Thanks & Regards Yours Faithfully, For L.V.Prasad Eye Institute 4 Sunita fe BN SiMallarjuna Rao Administrator - Accounts Encl: Aja LY Prasad Eye Instituce, GHR Varalakshmi Cam ip No. 13H yi thawako Junction, Visakbapatram - $30 040 | Tel; *91 0891 3564000,3964656 Fax; +91 089/ 3964444 Email: GMRV4 - , e@ivpé.orp Website: wivwlvpe ICICI Lombard : Picicr@Lombard ‘Health Care “Authorization Later tothe Hospital for the Treatment and Guarantee of Paysnent Ov-I8 LV. Prasad Bye Insitute AL. Number1 10200827684 GAR Verlakshini Campus, 11-1131, Hanumanthawaa tation ‘Viaskhapatnam Andhra Praesh-S30040 Tels Mob Dear SivMadur, {We berby authorize and yaar ox paymicat wp 0 Rs 19400 (in words) Ropoes NINETEEN THOUSAND FOUR HUNDRED cal for Admtsion Pre-Autoiztin rust note en ty yos withthe flowing nfraon ‘ame ofthe patent KSATYA RAO Lib Numer rua3e2ass304 Caso Accommodation Day Cae Fer Moviional Dag seni cat Poly Pei 30-MAR-2018 To 22-MAR-2019 Date of Admission con olicy Number :4016/147635 12200000 : Manis of Conporte ‘MEDIA SERVO DRIVES PRIVATE LIMITED “Date [aa Sonctbned Amount | ~ 13404 Remark Kindly note maximum anthoricatian has been zpproved as per MOU, henes further tmnt enhancements 08 tpproved and hespital is oquested nt Lo colect his difference amouat frm the patent, Final lum seunent sekaty as per MOU and Pay TAC. Paint paid amount along wih signature are wandatory nthe colume provided bow. Foray astles iets, wile oucahlssueqaesi@iidlanbard.com ce submit PAN of your hospital and Aachaar Number ofthe Authorizes Signtery (wth copy forsttemant ofthe moran: Te atonal fr Alison wis 1 slo te Dal ofAmasion me oro saci he Pe ge vhkeves reac Th Ahora bconcs oul and oH the pets ichgs bine ts dat of iste te kobe celeste om inate, lata Process Seen wl bem yr sss im MOUTHCA. Tg ‘heen peeted docu ths res Cie! Lombard Geter Insurance Company Lid, er Real inte Update peo in: ssw esis Hea Cans Fe eeaeee er Lambe CIC, ICICI Lonacd Health Ca, [CICL Bonk Tower, Pleo (2, Paani Dist, Navaleam Gu, Gash. Nyehnebat, 04932, Telangana, Toll FeeHelptine No: 1800 2 666, Tol Frc Fax No: 1800 209 $860, Fox No. Lin; 040.66049160/61, Pal Hheltheate@icklombard som IRDA Tiegatttinn Ne. 1S aoa: n ona - i ‘pen ao Fetlowing Details are masdstory or ean stdereat F [bat ortiechape [zane 3, DD a | [i Bit Amone 0/500 /- | ] uw [Amount Paid by Pains i200)- [SpnnavofthePuiotReative —[fowpitl Stamp & Sgnanze, | a eee ain ee rg enemnt we asenno etspate OTA Aicicr@rombard CASHLESS AUTHORIZATION REQUEST NOTE: Toll Fee ner: 1800 Ze66 + Fax Number 1800 209 6380/ 040 6E98 9180, 61 + Ernst us. casltessaques! TO SE FILLED BY THE INSURED /PATIENT EEDeeRsmSemREEE TT SSUNEEU Name fPatient MR KU PPILt} SHotye RAO TOendegr Ata Fert 3)ngeT Zeus, s)UarotSi sion “ralde TU NSE IU GS SHOU syemsitos__ UDIELIYT6 35122\00]000 Svar Pali 8) a) ConanatePatcyN, bl GerporrFoieyName _ }Emavee iD: ilyde aula anyotherhtedi Yes Na Ves, 10} tame family physica \urnber HYDMgePootAesched Aad ts _ MUREERGEENRESRESNNENEENNEE TBE FILLED BY THE TREATING DOCTOR /HOSPITAL semammammenemsstonsrearaen-% HlaiMonechihe resting doco Qe SBD wogc Codav vile: OSH - 39 SY 555 YeiNawectHowiut_L Vv PRASiD Loe STII the, TOBE SSTbBI cM ode. Ena: ginaucis rence @lypei olfexte. 6291-342 uuy rearran cin Serine eto BLooOpO VGinn ‘ak wissonie BAR \vewetcined snags: ALeRED wsSion2 Pasthiatry men, ang VFropbeedine al eeammenn: MostoalN t wr MOE EMV LSLELL Pe Loon. 4 Tol WM bAAOT LON FOR Tee Sec Gye pIeD Pe ‘hfeponeetatoice: FINN uta cstcbich ie ati 13}ellncase of aromiy Desa of te pao eaten Monday: Pant Wire ony ys since © DF it LRbIs OBLOODN che Hess Conta pliedtowilcaioveven? — Ereeey Ueboeet Detter ul) Expected no. of days stayin husstat CCF Days el Fcwn Type: 1 fsaase 5a De ¢ | vate son Logs : Heese IGN Bhaes: Consus bps opal 1 Sou ist ec RRAERETEMIMNE RRL [GLAM MOREE ‘in sati Saing ead untested ard sore! tthe Declarations onthe ravers lth ora D2 SippPyBOTH YADAV sacLfagttion He wait ste code PONE. forl2eae kendo Mame alse vesting wee ua ms Sgt of 72s tee u |PLense compere a sreeara AM AAA NOT TO BE FAXES, BY THEPATIENT REPRESENTATIVE lath explo sub oinl danas petit esptloutonte he lesr/TPA attr edscharge. age saan ‘leith Dsciagesunvrary boron dschane . vos tens ofthe sky. Ie hola: TPs ntlitlets sett the hospi bl, Lunteake sgileticht espe thetemeandeenstonsafthepsioy 2, yen is gooey ter ad 4A mnneical emenses ard experses eat clean to curust hogptaston and the anousts ovr B above helimt cutoraedDy tne et gern bythe and eadins fthepefeywilbepas tyme, Frere 4. loxey ecard thetems am eontens of eceteyan ita any me teas ces by mere our be fseor rene Mo rngshrvat ages to nde theese TBA 5. Leyoe ane useestanu tat RA‘ w ft wayveranicg the seviay a the hospi! 6 hath Insuar TP iinno ay qsrntacrg thatthe s-yeesueidadey hohosptol lect apatelar qty stn ety stat deta the ging pica in ewery cogent rl are att Thate ma oral aks any fer unt salen ‘ope ss on erconsezent wise tetecla ght a epumeretlthe sa xperes stb bach feted sovifcha hospitalist llpansesincared my bh wich ete nl dnkarse by Best TP Iraretstime MRM Sergprag sewenniie 44408 36 24 & dtiowshaets suet oserTALDECLARATION. 1. ‘Wwtuscnacteeont nj auhorzed TPA Cnrgany il vntying documents parsing spain. s2santoTPA/lsurareeCompary win? days ‘lund eraensdiycaurter net byt insu eer es perthe chet sow ro sale ecensts, OF senses no leva te hsatalaston eres, OR expenses cssbwed te Rutanzian Lt oe TAS ferauorin tee aulbarsabontarmill vcolecd Fo thepatit, ‘Ty puteitdelrnnlasbean sey hepato ebyhsepresenttis ouprese {Ws se owe elefeations orth gai ried raudng this hesptaleaton act we take the sole responsi a any daly in etn riers Doatorasigeawe FOr duaitiia DOCUIREVTS T0 BE PROVIDED BY THEMOSPTAL IW SUPPORT GF THE CLAM tle scheage Suneaeyanalaehomehehespial 2 Cosine tom re Hapits/Shemstssupperte oy pmper pes. Hhcupis ond Fatheogd Tt por Paulos, spat by rate Romy the alten Mil Patton /Sugesnecomnending syenpancoyesTests, 2 Suodsdenfcate sting raiee! ser onpafrmedan Surges land Recep 5. Contentes Pom altentngMedical Prattioaner / Suigeen Hatthepatiortistuly cured, 8 5 IMEDHA SERVO DRIVES PRIVATE LIMITED Namo: KSATYARAO : Policy No: 406/147635122100:000 Card No 5 1L13624683404 Empld : 008427 Gender: MALE : Valid From :30Mar18 To :23-Har-t8 jurgeangtaget ears Se: \ B® ‘g{0OUEIDENTIACATION AUTHORITY OF CI sso Ramsmur Sr man es LV PRASAD EYE INSTITUTE |e? GMR Vaialakshmi Camps, 11-113/1, MRNo: G~P13260) Date 24 ulig oouentment Junetion PabaleNane? Nice. Bio fisakhapatnam- §30 040 - - Consultant Dr. Ssday wth : ee NEXTAPPOINTMENT SURGICAL PROCEDURES FOLLOW UP | PRIMARY wey: Glaser Evans UNDER MEDICAL : . ' EBV AFTER WEEK(S) ROUTINE o 2A DAY(S) INVESTIGATION A SCAN oO TYPE OF SERVICE Oo OUT-PATIENT oO EXCLUSIVE oO Revs foe PREMIUM fi <= DELUXE § Oo ELITE a ‘STANDARD é ECONOMY : / oN SQ) DISCHARGED ON. “.)/I!/at rs ‘

    You might also like