United Healthcare Parekh Claim Form – Fill Out and Use This PDF

Fax us on: 022 -28528222

E-mail : nurseline.mumbai @uhcpindia.com

Name of Employee :

Employee Ref. no:

Company Name :

Mobile /Res:

Age /Sex:

Email ID:

Name of patient:

Relation with Employee:

Age/Sex:

Details of treating physician and hospital

Name of treating physician:

Reg. no:

Qualification:

**Mobile & Clinic No:

Name of hospital :

Location:

Email ID of Hospital:

Hospital registration no:

Tax approved:

Hosp. Tel. no:

Hosp. Fax no:

Details of diagnosis ( Kindly attach Investigation Reports relevant to the diagnosis)

**Presenting complaints on Admission :

**Duration of Ailment:

Previous H/O similar complaints:

Relevant Clinical Findings:

TPR/BP:

Other vital symptoms:

**Date of first onset of symptoms:

Date of first diagnosis:

**Diagnosis

1º

2º

Mandatory in R.T.A.

Mandatory in Maternity

Under the influence of Alcohol / Drug Abuse

-- Yes / No

LMP-

EDD-

G___P___A___L___

MLC / FIR Copy YES / NO ( Kindly Fax the copy)

Type of Delivery: Normal / LSCS -

Details of Accident:

Indication for LSCS:

In case of MTP: Voluntary / Medical (USG Report Mandatory)

Date of Admission:

Expected length of stay

Hospitalization Less than 24 hrs. No/ Yes

**Kindly specify the Names of Medicines:

Drugs (names compulsory)

Inject. ()

Oral ()

Drugs (Names

Inject. ()

Oral ()

Tick where Applicable

Antibiotics

compulsory)

Anti-inflam. drugs

Steroids

IV transfusions

Neuro-musc. drugs

Chemotherapy

Radiotherapy

Cardiac drugs

Sedatives

Blood Transfusion

Respiratory drugs

Diuretics

Continuous traction

Others

GI drugs

Intermittent traction

Names of Investigations supporting to Diagnosis:

**Surgical treatment/ Procedure:

**Type of Anaesthesia:

**Estimate Expenses

Note: *All the above

Past History

Class of Room

mentioned fields are required

**History of

:

Since

Room Rate / Day

to be filled in Block

Alcohol/Drug Abuse

–

Yes / No

Investigation (Attach Breakup)

letters.*Avoid over writing and

Tobacco Consumption

–

Yes / No

Consumables/Pharmacy (Attach Breakup)

abbreviations.*Strike out

Disease Ailment

Dr. Visit Charge

whichever is not

Dyslipidaemia

Surgeon Charge

applicable*Please provide

Diabetes

Anesthetist Charge

Hypertension

Discharge summary & Final

O.T. Charge

History of surgery

bill 3 hours prior to discharge

All inclusive Package Charges if applicable

History of similar Compliant

of the patient **Mandatory

Total Expenses

History of related Ailment

fields

DECLARATION

**Date : ___________________

**Hospital Stamp (Mandatory) Treating Physician Signature:_________________________

Note: Pre-authorization may cause

Kindly send all investigation reports and treatment sheets for all cases, FIR / MLC wherever applicable.

delay if documentation is incomplete

Kindly send photo ID of patient with hospital stamp.

or inaccurate

Kindly send complete itemized bill breakup during every enhancement request.