Sparsh Hospital Mysore Road (A Unit of Shiva & Shiva Orthopaedic Hospital Pvt Ltd)

8, Ideal Homes HBCS Layout, Javarandoddi,Rajarajeshwari Nagar, Bengaluru,

Karnataka,Bengaluru,Karnataka,India
GSTIN - 29AAICS6819E1Z1 | GST State Code - 29

IP Tax Invoice - Credit

From : 15 Oct 2024 To : 16 Oct 2024

Bill No. : PROVISIONAL UHID : 1400016122

Run Date : 16 Oct 2024 | 05:25 PM Patient Name : Mrs. N INDIRA
IP No. : MSR24IP4437 Age/Gender : 56 Yrs , F
Practitioner : Dr. SHYAM SUNDAR C M Address : NO 205 B BLOCK HALAGEVADARAHALLI ROAD, R R
Speciality : Endocrinology NAGAR BANGALORE, Rajarajeshwarinagar ,
Bed Category / Bed No. : SINGLE ROOM / 317 Bengaluru, Karnataka, India, 560098
Nursing Unit : Third Floor North Wing_MSR Mobile No : 9980637301
Payor : MEDI ASSIST INDIA LTD
Admission Date : 15 Oct 2024 | 06:44 AM
Sponsor : THE NEW INDIA ASSURANCE COMPANY LIMITED
Discharge Date :
Plan : CREDIT
Discharge Status : Normal
Payor Category : Insurance
GSTIN :

Service Date Service Name

a l Rate Qty
Gross
Amount
Net
Amount
Patient
Payable
Payor
Payable

n
CONSULTATION VISIT (SAC- 999311)

o
15 Oct 2024 VISIT-SPECIALITY (CODO0001) || Dr. SHYAM SUNDAR C M 1,300.00 1 1,300.00 1,300.00 0.00 1,300.00
16 Oct 2024
16 Oct 2024
VISIT-SPECIALITY || Dr. SHYAM SUNDAR C M

is
VISIT-SUPER SPECIALITY (CODO0002) || Dr. PRASHANTH B GANDHI
i 1,300.00
1,300.00
1
1
1,300.00
1,300.00
CONSULTATION VISIT (SAC- 999311) Total 3,900.00
1,300.00
1,300.00
3,900.00
0.00
0.00
0.00
1,300.00
1,300.00
3,900.00
Room Rent (SAC- 999311)
15 Oct 2024 -
SINGLE ROOM (RORO0004)

o v 4,330.00 2 8,660.00 8,660.00 0.00 8,660.00

r
16 Oct 2024
Room Rent (SAC- 999311) Total 8,660.00 8,660.00 0.00 8,660.00
ACCIDENT & EMERGENCY (SAC- 999311)
15 Oct 2024
15 Oct 2024
15 Oct 2024
P
GRBS (PAEM035) || Dr. SHYAM SUNDAR C M
IV CANNULATION (PAEM049) || Dr. SHYAM SUNDAR C M
GRBS (PAEM035) || Dr. SHYAM SUNDAR C M
190.00
190.00
190.00
1
1
2
190.00
190.00
380.00
190.00
190.00
380.00
0.00
0.00
0.00
190.00
190.00
380.00
15 Oct 2024 GRBS (PAEM035) || Dr. SHYAM SUNDAR C M 190.00 1 190.00 190.00 0.00 190.00
15 Oct 2024 GRBS (PAEM035) || Dr. SHYAM SUNDAR C M 190.00 1 190.00 190.00 0.00 190.00
16 Oct 2024 GRBS (PAEM035) || Dr. SHYAM SUNDAR C M 190.00 1 190.00 190.00 0.00 190.00
16 Oct 2024 GRBS (PAEM035) || Dr. SHYAM SUNDAR C M 190.00 1 190.00 190.00 0.00 190.00
16 Oct 2024 GRBS (PAEM035) || Dr. SHYAM SUNDAR C M 190.00 1 190.00 190.00 0.00 190.00
16 Oct 2024 GRBS (PAEM035) || Dr. SHYAM SUNDAR C M 190.00 2 380.00 380.00 0.00 380.00
ACCIDENT & EMERGENCY (SAC- 999311) Total 2,090.00 2,090.00 0.00 2,090.00
ADMISSION CHARGES (SAC- 999311)
15 Oct 2024 ADMISSION CHARGES (ADAD0002) || IPB 870.00 1 870.00 870.00 0.00 870.00
15 Oct 2024 Documentation / Processing Fee (ADM009) || IPB 740.00 1 740.00 740.00 0.00 740.00
ADMISSION CHARGES (SAC- 999311) Total 1,610.00 1,610.00 0.00 1,610.00
CARDIOLOGY (SAC- 999311)
15 Oct 2024 ECG (PCAR005) || Dr. SHYAM SUNDAR C M 530.00 1 530.00 530.00 0.00 530.00
CARDIOLOGY (SAC- 999311) Total 530.00 530.00 0.00 530.00
FOOD AND BEVERAGES (SAC- 999311)
15 Oct 2024 DIETICIAN CHARGES (DIET001) || Dr. NUTRITION AND DIET 640.00 1 640.00 640.00 0.00 640.00
FOOD AND BEVERAGES (SAC- 999311) Total 640.00 640.00 0.00 640.00
GASTRO MEDICAL (SAC- 999311)
16 Oct 2024 GASTROSCOPY BIOPSY (PGAM151) || Dr. PRASHANTH B GANDHI 8,310.00 1 8,310.00 8,310.00 0.00 8,310.00
GASTRO MEDICAL (SAC- 999311) Total 8,310.00 8,310.00 0.00 8,310.00
LABORATORY SERVICES (SAC- 999311)
15 Oct 2024 COMPLETE BLOOD COUNT(CBC) (LHAE033) || Third Floor North Wing_MSR 300.00 1 300.00 300.00 0.00 300.00
15 Oct 2024 RENAL PROFILE (RFT) (LBIO797) || Third Floor North Wing_MSR 950.00 1 950.00 950.00 0.00 950.00
15 Oct 2024 HBA1C (LBIO488) || Third Floor North Wing_MSR 1,020.00 1 1,020.00 1,020.00 0.00 1,020.00

Page 1 of 4
Bill No. : PROVISIONAL UHID : 1400016122
Run Date : 16 Oct 2024 | 05:25 PM Patient Name : Mrs. N INDIRA
IP No. : MSR24IP4437 Age/Gender : 56 Yrs , F
Practitioner : Dr. SHYAM SUNDAR C M Payor : MEDI ASSIST INDIA LTD
Speciality : Endocrinology Sponsor : THE NEW INDIA ASSURANCE COMPANY LIMITED
Bed Category / Bed No. : SINGLE ROOM / 317

CORTISOL, SERUM (MORNING SAMPLE, 6 to 10am) (LBIO283) || Third Floor

15 Oct 2024 1,020.00 1 1,020.00 1,020.00 0.00 1,020.00
North Wing_MSR
THYROID FUNCTION TESTS (TOTAL T3, TOTAL T4, TSH) (LBIO860) || Third
15 Oct 2024 1,400.00 1 1,400.00 1,400.00 0.00 1,400.00
Floor North Wing_MSR
15 Oct 2024 ANA PROFILE (LMIC042) || Third Floor North Wing_MSR 11,240.00 1 11,240.00 11,240.00 0.00 11,240.00
16 Oct 2024 HISTOPATHOLOGY SMALL BIOPSY (LHIS209) || Third Floor North Wing_MSR 1,530.00 1 1,530.00 1,530.00 0.00 1,530.00
LABORATORY SERVICES (SAC- 999311) Total 17,460.00 17,460.00 0.00 17,460.00
MEDICAL EQUIPMENTS (SAC- 999311)
15 Oct 2024 EQP - Infusion Pump - Per Day | MEDEQP037 (MEDEQP037) || || IPB 530.00 1 530.00 530.00 0.00 530.00
MEDICAL EQUIPMENTS (SAC- 999311) Total 530.00 530.00 0.00 530.00
MISCELLANEOUS (SAC- 999311)
15 Oct 2024 REGISTRATION CHARGES (ADAD0003) || EMR 70.00 1 70.00 70.00 0.00 70.00

NURSING (SAC- 999311)

a l
MISCELLANEOUS (SAC- 999311) Total 70.00 70.00 0.00 70.00

n
15 Oct 2024 NURSING CHARGES (NUNU0001) || IPB 3,090.00 1 3,090.00 3,090.00 0.00 3,090.00
16 Oct 2024 NURSING CHARGES 3,090.00 1 3,090.00 3,090.00 0.00 3,090.00

i o
NURSING (SAC- 999311) Total 6,180.00 6,180.00 0.00 6,180.00

is
RADIOLOGY (SAC- 999311)
15 Oct 2024 CT Abdomen And Pelvis With Contrast (RAD0016) || Third Floor North Wing_MSR 18,240.00 1 18,240.00 18,240.00 0.00 18,240.00
15 Oct 2024

o v
CT SCREENING(ABDOMEN/CHEST) (RAD0143) || Dr. SHYAM SUNDAR C M 5,260.00 1 5,260.00 5,260.00
RADIOLOGY (SAC- 999311) Total 23,500.00 23,500.00
0.00 5,260.00
0.00 23,500.00
Cardiology Services (SAC- 999311)
16 Oct 2024

CENTRAL PHARMACY STORE_MSR

P r
2D ECHO (CAR001) || Third Floor North Wing_MSR 3,880.00 1
Cardiology Services (SAC- 999311) Total
3,880.00
3,880.00
3,880.00
3,880.00
0.00
0.00
3,880.00
3,880.00

Issue
15 Oct 2024 HUMAN ACTRAPID 40IU 10ML INJ - Batch: B-70843 - Exp.: Aug/2026 178.29 1 178.29 178.29 0.00 178.29
ONDAFINE 2ML INJ AEQUITAS HEALTHCARE PVT LTD - Batch: RA4102 - Exp.:
15 Oct 2024 13.35 2 26.70 26.70 0.00 26.70
Aug/2026
PRASOPHEG 40MG INJ PANTOPARAZOLE INJECTION 40MG AEQUITAS
15 Oct 2024 56.50 2 113.00 113.00 0.00 113.00
(SANDOZ) HEALTHCARE - Batch: D24JR011A - Exp.: Jul/2026
15 Oct 2024 ORS L PLUS ORANGE TETRAPACK - Batch: SK40085 - Exp.: Jun/2025 45.00 2 90.00 90.00 0.00 90.00
IV CANNULA VASOFIX SAFETY 20G B. BRAUN MEDICAL (INDIA) PVT. LTD. -
15 Oct 2024 350.00 1 350.00 350.00 0.00 350.00
Batch: 23M25G8381 - Exp.: Nov/2028
TEGADERM 6.5CM X 7CM 1683 3M 3M INDIA LIMITED - Batch: R08240901 -
15 Oct 2024 262.00 1 262.00 262.00 0.00 262.00
Exp.: Jul/2027
15 Oct 2024 INSULIN SYRINGE 100IU BD - Batch: 2241338 - Exp.: Sep/2027 9.40 3 28.20 28.20 0.00 28.20
EASYFIX CLEAR IV FILM 7CM X8.5 CM EC1H+ DYNA - Batch: 123 - Exp.:
15 Oct 2024 205.00 1 205.00 205.00 0.00 205.00
Jan/2027
IV CANNULA VASOFIX SAFETY 20G B. BRAUN MEDICAL (INDIA) PVT. LTD. -
15 Oct 2024 350.00 1 350.00 350.00 0.00 350.00
Batch: 23M25G8381 - Exp.: Nov/2028
15 Oct 2024 IV SET NOVOFUSION - POLYMED - Batch: 6277524H - Exp.: Jul/2029 258.00 3 774.00 774.00 0.00 774.00
NORMAL SALINE 0.9%W/V 500ML STERIPORT AMANTA - Batch: 50640645 -
15 Oct 2024 98.50 3 295.50 295.50 0.00 295.50
Exp.: Aug/2027
NORMAL SALINE 0.9% W/V STERIPORT 100ML AMANTA - Batch: 50640692 -
15 Oct 2024 47.11 4 188.44 188.44 0.00 188.44
Exp.: Aug/2027
SYRINGE 10ML WITH NEEDLE PERFECTUM HMD HMD - Batch: 436104NG2 -
15 Oct 2024 43.00 3 129.00 129.00 0.00 129.00
Exp.: Aug/2029
SANITIZER HAND ETHYL ALCOHOL 500ML SHAMNUR - Batch: 456 - Exp.:
15 Oct 2024 250.00 1 250.00 250.00 0.00 250.00
Jan/2027
CLAVE CONNECTOR (Q-SYTE) (385103/385100) - Batch: BATCH1 - Exp.:
15 Oct 2024 182.00 1 182.00 182.00 0.00 182.00
Jun/2029
NS 3% 100ML GLASS BOTTLE 0.03 NILRISE PHARMACEUTICALS PVT LTD -
15 Oct 2024 173.00 1 173.00 173.00 0.00 173.00
Batch: 2403042028 - Exp.: Jun/2027
15 Oct 2024 ONDERO 5MG TAB - Batch: UA01265 - Exp.: May/2026 17.49 5 87.45 87.45 0.00 87.45

Page 2 of 4
Bill No. : PROVISIONAL UHID : 1400016122
Run Date : 16 Oct 2024 | 05:25 PM Patient Name : Mrs. N INDIRA
IP No. : MSR24IP4437 Age/Gender : 56 Yrs , F
Practitioner : Dr. SHYAM SUNDAR C M Payor : MEDI ASSIST INDIA LTD
Speciality : Endocrinology Sponsor : THE NEW INDIA ASSURANCE COMPANY LIMITED
Bed Category / Bed No. : SINGLE ROOM / 317

15 Oct 2024 TELMA-AM 40/5MG TAB - Batch: 18230669 - Exp.: Sep/2026 19.50 5 97.50 97.50 0.00 97.50
UNDERPAD 60CM X90CM YESHASWI HYGIENE - Batch: BATCH1 - Exp.:
15 Oct 2024 230.00 2 460.00 460.00 0.00 460.00
Sep/2029
15 Oct 2024 CLAVE CONNECTOR - 13341 - POLYMED - Batch: 1054024E - Exp.: Apr/2029 609.00 1 609.00 609.00 0.00 609.00
EXAMINATION GLOVES POWDER FREE (SMALL) NITRILE MATIG - Batch:
15 Oct 2024 15.00 10 150.00 150.00 0.00 150.00
BATCH1 - Exp.: Sep/2029
SYRINGE 10ML WITH NEEDLE PERFECTUM HMD HMD - Batch: 436104NG2 -
15 Oct 2024 43.00 4 172.00 172.00 0.00 172.00
Exp.: Aug/2029
SYRINGE 2.5ML WITH NEEDLE PERFECTUM HMD - Batch: BATCH1 - Exp.:
15 Oct 2024 19.00 4 76.00 76.00 0.00 76.00
Oct/2029
SYRINGE 5ML WITH NEEDLE PERFECTUM HMD - Batch: 421055NF1 - Exp.:
15 Oct 2024 23.00 4 92.00 92.00 0.00 92.00
Feb/2029
15 Oct 2024 POLYFLUSH 10ML SYRINGE - POLYMED - Batch: 8287624F - Exp.: May/2027 76.00 4 304.00 304.00 0.00 304.00
16 Oct 2024

16 Oct 2024
INSULIN SYRINGE 100IU BD - Batch: 2241338 - Exp.: Sep/2027
PRASOPHEG 40MG INJ PANTOPARAZOLE INJECTION 40MG AEQUITAS
(SANDOZ) HEALTHCARE - Batch: D24JR011A - Exp.: Jul/2026

a l 9.40

56.50
3

2
28.20

113.00
28.20

113.00
0.00

0.00
28.20

113.00

16 Oct 2024
Aug/2026

o n
ONDAFINE 2ML INJ AEQUITAS HEALTHCARE PVT LTD - Batch: RA4102 - Exp.:
13.35 2 26.70 26.70 0.00 26.70

Return

16 Oct 2024
Batch: 23M25G8381 - Exp.: Nov/2028

is i
IV CANNULA VASOFIX SAFETY 20G B. BRAUN MEDICAL (INDIA) PVT. LTD. -
-350.00 -1 -350.00 -350.00 0.00 -350.00

v
TEGADERM 6.5CM X 7CM 1683 3M 3M INDIA LIMITED - Batch: R08240901 -
16 Oct 2024 -262.00 -1 -262.00 -262.00 0.00 -262.00
Exp.: Jul/2027

16 Oct 2024

16 Oct 2024
Jun/2029

r o
CLAVE CONNECTOR (Q-SYTE) (385103/385100) - Batch: BATCH1 - Exp.:

INSULIN SYRINGE 100IU BD - Batch: 2241338 - Exp.: Sep/2027

-182.00

-9.40
-1

-3
-182.00

-28.20
-182.00

-28.20
0.00

0.00
-182.00

-28.20

16 Oct 2024

16 Oct 2024
Feb/2029
P
SYRINGE 5ML WITH NEEDLE PERFECTUM HMD - Batch: 421055NF1 - Exp.:

SYRINGE 10ML WITH NEEDLE PERFECTUM HMD HMD - Batch: 436104NG2 -

Exp.: Aug/2029
-23.00

-43.00
-3

-3
-69.00

-129.00
-69.00

-129.00
0.00

0.00
-69.00

-129.00

SYRINGE 2.5ML WITH NEEDLE PERFECTUM HMD - Batch: BATCH1 - Exp.:

16 Oct 2024 -19.00 -3 -57.00 -57.00 0.00 -57.00
Oct/2029
16 Oct 2024 POLYFLUSH 10ML SYRINGE - POLYMED - Batch: 8287624F - Exp.: May/2027 -76.00 -3 -228.00 -228.00 0.00 -228.00
NORMAL SALINE 0.9% W/V STERIPORT 100ML AMANTA - Batch: 50640692 -
16 Oct 2024 -47.11 -4 -188.44 -188.44 0.00 -188.44
Exp.: Aug/2027
16 Oct 2024 IV SET NOVOFUSION - POLYMED - Batch: 6277524H - Exp.: Jul/2029 -258.00 -1 -258.00 -258.00 0.00 -258.00
EXAMINATION GLOVES POWDER FREE (SMALL) NITRILE MATIG - Batch:
16 Oct 2024 -15.00 -8 -120.00 -120.00 0.00 -120.00
BATCH1 - Exp.: Sep/2029
16 Oct 2024 ORS L PLUS ORANGE TETRAPACK - Batch: SK40085 - Exp.: Jun/2025 -45.00 -1 -45.00 -45.00 0.00 -45.00
ONDAFINE 2ML INJ AEQUITAS HEALTHCARE PVT LTD - Batch: RA4102 - Exp.:
16 Oct 2024 -13.35 -2 -26.70 -26.70 0.00 -26.70
Aug/2026
CENTRAL PHARMACY STORE_MSR Total 3,867.64 3,867.64 0.00 3,867.64
ENDOSCOPY_MSR
Issue
UNDERPAD 60CM X90CM YESHASWI HYGIENE - Batch: BATCH1 - Exp.:
16 Oct 2024 230.00 1 230.00 230.00 0.00 230.00
Sep/2029
16 Oct 2024 PLASTIC APRON DISPOSABLE - STERILE - Batch: 01 - Exp.: Jan/2027 100.00 1 100.00 100.00 0.00 100.00
16 Oct 2024 MOUTH GUARD - Batch: G1014 - Exp.: Nov/2028 65.00 1 65.00 65.00 0.00 65.00
16 Oct 2024 ENDOVIEW EMULSION 15ML - Batch: EVE24006 - Exp.: May/2026 89.00 1 89.00 89.00 0.00 89.00
ENDOSCOPY_MSR Total 484.00 484.00 0.00 484.00
Bill Status : Unsettled Bill Total 81,711.64 81,711.64 0.00 81,711.64

Amount in Words: INR Eighty One Thousand Seven Hundred Eleven and paise Sixty Four only

Gross Amount 81,711.64

Net Amount 81,711.64
Taxable Amount 0.00

Page 3 of 4
Bill No. : PROVISIONAL UHID : 1400016122
Run Date : 16 Oct 2024 | 05:25 PM Patient Name : Mrs. N INDIRA
IP No. : MSR24IP4437 Age/Gender : 56 Yrs , F
Practitioner : Dr. SHYAM SUNDAR C M Payor : MEDI ASSIST INDIA LTD
Speciality : Endocrinology Sponsor : THE NEW INDIA ASSURANCE COMPANY LIMITED
Bed Category / Bed No. : SINGLE ROOM / 317

CGST 0.00
SGST 0.00
Total Amount (With GST) 81,711.64
Net Payable by Patient 0.00

Advance/Refund Detail Payor Payable 81,711.64

Receipt Receipt Adjusted Payment Refund Payor Balance 81,711.64

Amount
No. Date Amount Mode Amount

a l
o n
Bill Remark:

is i
Patient's/Attendent's Signature
Kin Name: DEEPA

o v
Kin Relation: Daughter Kin Contact: 9980637301
Prepared By:

P rPrinted By: Maruthi M Print Date: 16 Oct 2024 | 05:25 PM

Page 4 of 4