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BAJ AJ I Alllanz(ffi)
Bajaj AUianz General Insurance
Co ; Ltcf ,
ANNEXUREB
Pre-Authorization for Cashless Facility
Hospital Code: BAGIC H : 363
•. "0
'
BAJAJ ALUANZ GENERAL INSURANCE CO. LID;
Ground Floor Ashoka Plaza
32/2 Nagar Road, Wadgaon Sheri
Pune - 411 014
Phone: 1800 1025858 (ToU Free) / (020) - 26500203/232/242/30512229/232 (STD). Fa x: (020)-30512224/226/227
Email: health@bajajallianz;co.in
.
Beneficiary Name:
L. D. Card No, __________ ,-- __
Expected Date of Adm ission :
Age/Sex: _ -'- __
Name of Treating Doctor: ,
days
.Registration No .: _______________ _,_-----"-PD
Name
of. Hospital:
City _Mumbai State_Maharashtra
.~
Policy No,
__________ E xpected L ength of Sta y:
HINDUJA
Details of Signs and Symptoms related to the present ailmenn ,
Duration of AiIrr ient:
NATIONAL
HOSP ITAL
MEDICAL
&
RESEARC
H
CENTRE
__________________ ~ _____________ _'_ ________ .:... ______ __' ________ _
Provisional Diagnosis: __ _'_ _ __' __ __'~_-'-,.:- __________ "__.:... _________________ _
PLEASE STATE IF THERE IS PAST HISTORY OF THE FOLLOWING AND DURATION;
Disease / Ailment
I lypcrtcnsion/' cardiovascular diseases
Diabetes
Asthma
. "fir
SUfl..'I.:rv/hospitali%ation
I'm- other disease I disnbilirv
Obstetric 1 Iistory / Past Ob / (;y Sur~<:r)'
. Past History
(Yes /No
(Yes /No
(Yes INo
(Yes /No
(Yes /No
Duration/ other deuils
Status: G .....~ .~ P. .••...... A ..•••... .1 ...•..• Lj\[j>; •................... , .................
Wa:''<thc illness or injury due to the use of
a1c()I\(~1O rintoxicatinu Jrug,;?
Intentional self injuf\ '
(Yes / No)
(Yes / No)
Medications if any during this hospit alization _____________ \-'- ____________________________________________
'-- "",,-
/J .:
~---- -'-------------- __
Relevant Clinica l Findings: __ __'~-' __ --:.. __ _'_ __ ~ _______________________________________________________
-Investigations Report (if any): ~
Proposed Line of Treatment:
Details of treatment received!
_______________ .:... ______________________________
...,.-------------- --
__' __________________________ _,_- ....:.---
____________________________ ~ ____________ -:-- __ .... ,.. ________ ------'--------_ :___' _ __' _____________________ -'--'- _______ -'-' ____________ ..:...., __________ __' _______________ -'- __
Estimate of Exp ~~eS:TotaIAmou~t -'-~. Class of accommodation: __
Expense: Head
...:.. ___________________________________________________
Amount
Expense: Head
Amount (Rs.)
(Rs.) .
'-
ROOM RENT
---~-
'-
INVESTIGAT IONS
...
DOCTOR / CONSULTANT VISIT CHARGES
MEDICINES/CONSUMABLES .
.
SURGEON CHARGgs
.'
OPERATION THEATRE CHARGES
EQUIPMENT/MONITOR ETC
MISCE UANEOUS (SPECIFY) ..
,
I· haw completed rhis (onTi : II1J will be responsible for correctness of till: me .•. licll! infclml;uio,l certified b)' m<'.
Signature of poet o r:
""l";-"''''T ft-rT ''TJ r
r-, r """<: -TTP "-'l'
.
•••. Tf'l"" )I'::' 0T:l"; "TC'TTnT ;''' !'t:
.Contact No: ~ .____________ ~ _________ _
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