Case D.

told
detailstreatment
Intial
Doctor's
Referal
Pre Details
consultation
detail First Onset documents
of information
|Ailment
details Registration
details(Attach Treatment
hospitalOtherandHospital Occupation Brief
Details
Policy
|Cashless/Non-cashless
Diagnosis
Historyetc)|Pre-AuthAdmission
DetailsICU Date Datedetails
|Claim Policy
Type PolicyCCN/PA proof
Age DateofName
PolicyNo Birth/Age
Hosp Details(Amount,Estimates,
Medical
and and of
ohaat t holder of the
Inv symtoms Name the Assist
Medi
Time Time case
and sheet
Name Insured
and of of
Treatment and Admission
Discharge
Address and
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related
Relation
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 ADDRESSS |Outcome
|Investigations
Suggesting |details Post
|Diagnosis
Ho LIST OPINION
INTERVEW
INSURED' DETAILS
S INSURED'
Signature Hosp
Ds OF
(ii) (i) (i) Assist
Medi
DOCUMENTS
Photography/copy
Copy (Attach Inv
Rlambu)
PoPTuhes- Copy
and
of of
.abi different
Indoor relevant treatment

COLLECTED
case
pathology copies)
of
papers/investigation Pan
Card/Voter
test
pate:, etc RBTEc
ATml ID
of
papers/discharge the au
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claimant
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summary albwd chest
Place

yAy
to
Dr. tbe
do khlBodinyat
clr 70,Regn. PS.
RAAJAORTHOCENTRE
THENI-625N.5R31.T paotes
, Alnandka 98969
No:
FhCose
Main
Lenin
ept M.S(Ortho)., ws
PÊ
Road, oY
Rajha.
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Cas