Claim Form - ‘CARE’

Part B

1. To be filled in by the hospital.

2. The issue of this Form is not to be taken as an admission of liability.
3. Please include the original pre-authorization request form in lieu of PART A.
4. To be filled in block letters.

Section A - Details of Hospital

a) Name of the Hospital :

b) Hospital ID :
c) Type of Hospital : Network Non-network (if non-network fill section E)
d) Name of the treating doctor :
(Surname) (First Name) (Middle Name)

e) Qualification :
f) Registration No. with State Code :
g) Contact No. :

Section B - Details of the Patient Admitted

a) Name of the Patient:
(Surname) (First Name) (Middle Name)

b) IP Registration No. :
c) Gender : M F d) Age : / (YY/MM) e) Date of Birth : / /
f) Date of Admission : / / (DD/MM/YYYY) g) Time of Admission : : (HH:MM)

h) Date of Discharge : / / (DD/MM/YYYY) i) Time of Discharge : : (HH:MM)

j) Type of Admission : Emergency Planned Day Care Maternity

k) If Maternity,
(i) Date of Delivery : / / (DD/MM/YYYY) (ii) Gravida Status : ________________________________
l) Status at the time of discharge : Discharge to home Discharge to another hospital Deceased
m) Total Claimed Amount :

Section C - Details of Ailment Diagnosed (Primary)

a) (i) Primary Diagnosis : ICD 10 Code : Description : ________________________________________________________
(ii) Additional Diagnosis : ICD 10 Code : Description : ________________________________________________________
(iii) Co-morbidities : ICD 10 Code : Description : ________________________________________________________
(iv) Co-morbidities : ICD 10 Code : Description : ________________________________________________________
b) (i) Procedure 1 : ICD 10 Code : Description : ________________________________________________________
(ii) Procedure 2 : ICD 10 Code : Description : ________________________________________________________
(iii) Procedure 3 : ICD 10 Code : Description : ________________________________________________________
(iv) Details of Procedure : ___________________________________________________________________________________________________

c) Present ailment is a complication of PED : Yes No

If yes, specify details : _________________________________________________________________________________________

d) Pre-authorization obtained : Yes No

e) Pre-authorization no. :

f) If authorization by network hospital not obtained, give reason : ______________________________________________________________________

__________________________________________________________________________________________________________________________

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001 (Haryana)
Website: www.careinsurance.com E-mail: customerfirst@careinsurance.com Call us: 1800-102-4488 | 1800-102-6655 Page 7
CIN: U66000DL2007PLC161503 UIN: RHIHLIP21017V052021 IRDA Registration No. - 148
g) Hospitalization due to Injury : Yes No

(i) If yes, give cause : Self inflicted Road Traffic Accident Substance Abuse/Alcohol Consumption

(ii) If Injury due to Substance abuse/Alcohol consumption, Test conducted to establish this : Yes No
(If yes, attach reports)

(iii) If Medico Legal : Yes No

(iv) Reported to Police : Yes No

(v) FIR No. :

(vi) If not reported to Police, give reason : ______________________________________________________________________________

Section D - Claim Documents Submitted - Checklist

(I) Duly signed Claim Form : (ix) Investigation Report :

(ii) Original Pre-authorization request : (x) CT/ MRI/ USG /HPE investigation reports :

(iii) Copy of Pre-authorization approval letter : (xi) Doctor's reference slip for investigation :

(iv) Copy of photo ID card of patient verified by hospital : (xii) ECG :

(v) Hospital Discharge Summary : (xiii) Pharmacy Bills :

(vi) Operation Theatre notes : (xiv) MLC report & Police FIR :

(vii) Hospital Main Bill : (xv) Original death summary from hospital where applicable:

(viii) Hospital Break-up Bill : (xvi) Any other, please specify_____________________ :

Section E - Additional Details in case of Non-Network Hospital (Only fill in case of non-network hospital)

a) Address of the Hospital :

City :
State : Pin Code :
b) Contact No. : -
c) Registration No. with State Code :
d) Hospital PAN : e) No. of inpatient beds :
f) Facilities available in the hospital : (i) OT : Yes No (ii) ICU : Yes No
(iii) Others : _____________________________________________________________________________________________________________

Section F - Declaration by the Hospital

(Please read very carefully)
We 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 facts, our right to claim under this claim shall be forfeited.

Date : / / (DD/MM/YYYY) Signature & Seal of the Hospital Authority : _________________

Place : _____________________________________________

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001 (Haryana)
Website: www.careinsurance.com E-mail: customerfirst@careinsurance.com Call us: 1800-102-4488 | 1800-102-6655 Page 8
CIN: U66000DL2007PLC161503 UIN: RHIHLIP21017V052021 IRDA Registration No. - 148