For a request of a Cashless Hospitalization of your Health Insurance Policy scan or fax the completed first two pages of this form to the Bajaj Allianz Claim office numbers at Fax: 020-30512224/6/7 or you can also submit the copies manually by visiting the claim office. This form is only valid if you have a Bajaj Allianz Health Insurance policy which is valid.
Bajaj Allianz General Insurance Company Limited.
Regd. & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006
Health Administration Team : *A – Wing 2nd Floor, Bajaj Finserv Building, Behind Weikfield IT Park, Off Nagar Road, Viman Nagar | Pune – 411 014
Phone No.: 020-30305858/ 1800-103-2529 Fax: 020-30512224/ 6/ 7 (To be filled in block letters)
Email: [email protected]
CASHLESS FORM
PLEASE FAX/SCAN PAGE 1 AND 2 ONLY
REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICAL INSURANCE POLICY
DETAILS OF THE PROVIDER
Hospital Name/nursing Home Name:
City Name:
State Name:
Pin Code:
Hosp Id:
Landmark:
TO BE FILLED BY THE INSURED/PATIENT
a) Name of the Patient:
b) Gender: Male
Female
c) Age: Years Y Y Months M M d) Date of birth: D D M M Y Y Y Y
e) Name of the Attendant:
f) Contact number, if any:
g)Contact number:
h) Insured card ID number:
I) Policy number I Name of corporate:
j) Employee ID:
k) Currently do you have any other Mediclaim / Health insurance:
Yes
No
Company Name:
Give details
l) Do you have a family physician:
Yes
No m) Name of the family physician:
n)Contact number, if any:
(PLEASE COMPLETE DECLARATION ON THE REVERSE SIDE OF THIS FORM)
TO BE FILLED BY THE TREATING DOCTOR / HOSPITAL
a) Name of the treating doctor: b) Contact number:
c) Nature of ILLNESS / Disease d) Relevant clinical
with presenting complaints findings:
e) Duration of the present ailment: Days i. Date of first consultation:
i. Past history of present ailment if any: ii. ICO 10 Code:
g) Proposed line of treatment: Medical Management Surgical Management Intensive care
Investigation Non allopathic treatment
D D M M Y Y Y Y
h) If Investigation & I or Medical Management provide details
i) Route of drug administration:
i) If Surgical, name of surgery:
j) If other treatments provide details:
k) How did injury occur:
I) In case of accident: i. Is it RTA: Yes
iii. Reported to Police: Yes No
No ii. Dale of injury:
iv. FIR No .
i. ICD 10 PCS Code:D D M M Y Y Y Y
SECTION
A
SECTION SECTION
v. Injury/Disease caused due to substance abuse/alcohol consumption:
Yes
No
vi. Test conducted to establish this Yes
G
P
L
A
:
No (If Yes attach reports)
I) In case of Maternity:
Date of Delivery:LMP:D D M M Y Y Y Y D D M M Y Y Y Y
Details of the patient admitted
Mandatory: Past History of any
chronic illness (If yes, since (month / year)
a) Date of admission:
D D M M
b) Time:
Y Y
:
H H
Diabetes
M M
c) Is this an emergency/a planned hospitalization event?:Emergency Planned
Heart Disease
d) Expected no. of days stay in hospital:Days e) Room Type
Hypertension
SECTION
f) Per Day Room Rent + Nursing & Hyperlipidemia
Service Charges + Patient’s Diet: Rs. Osteoarthritis
g) Expected cost for investigation + diagnostics.: Rs. Asthma / COPD / Bronchitis
h) ICU Charges: Rs. Cancer
i) OT Charges: Rs. Alcohol or drug abuse
j) Professional fees Surgeon + Anesthetist Fees + Rs. Any HIV or STD / Related ailments
consultation Charges Any other Ailment give details:
k) Medicines + Consumables + Cost of Implants Rs.
specify). Other hospital expenses if any:
l) All inclusive package charges if any applicable Rs.
m) Sum Total expected cost of hospitalization Rs.(PLEASE READ VERY CAREFULLY)
DECLARATION
We confirm having read understood and agreed to the Declarations on the reverse of this form
a) Name of the treating doctor:
b) Qualification:
c) Registration No. with State Code:Hospital Seal (Must include Hospital ID) Patient Insured Name & Signature
PAGE 3: NOT TO BE FAXED/SCANNED
DECLARATION BY THE PATIENT / REPRESENTATIVE
1. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TPA after the discharge. I agree to sign
on the Final Bill & the Discharge Summary, before my discharge.
2. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / TPA is not liable to settle the hospital bill, I
undertake to settle the bill as per the terms and conditions of the policy.
3. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the
Insurer/TPA not governed by the terms and conditions of the policy will be paid by me.
4 . I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect
I forfeit my claim and agree to indemnify the Insurer / TPA
5 . I agree and understand that TPA is in no way warranting the service of the hospital & that the Insurer / TPA is in no way guaranteeing
that the services provided by the hospital will be of a particular quality or standard.
6 . I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement
suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited.
7 . I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer /TPA.
a) Patient’s / insured’s Name:
b) Contact number: c) Patient’s / Insured’s Signature:
HOSPITAL DECLARATION
1. We have no objection to any authorized Bajaj Allianz General Insurance Company Limited official verifying documents pertaining to
hospitalization.
2. All valid original documents duty countersigned by the insured I patient as per the checklist below will be sent to Bajaj Allianz General Insurance
Company Limited within 7 days of the patient’s discharge.
3. All non medical expenses, OR expenses not relevant to hospitalization or illness, OR expenses disallowed in the Authorization Letter of the Bajaj
Allianz General Insurance Company Limited, OR arising out of incorrect information in the pre-authorisation form will be collected from the
patient.
4. WE AGREE THAT BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED WILL NOT BE LIABLE TO MAKE THE PAYMENT IN THE EVENT OF ANY
DISCREPANCY BETWEEN THE FACTS IN THIS FORM
AND DISCHARGE SUMMARY or other documents.
5. The patient declaration has been signed by the patient or by his representative in our presence.
6. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering
clarifications.
7. We will abide by the terms and conditions agreed in the MOU.
Hospital Seal Doctor’s Signature
DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM
1. Detailed Discharge Summary and all Bills from the hospital
2. Cash Memos from the Hospitals / Chemists supported by proper prescription.
3. Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner I Surgeon
recommending such pathological Tests.
4. Surgeon’s Certificate stating nature of operation performed and Surgeon’s Bill and Receipt.
5. Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured.