form 2

Reimbursement Application Form

ISHA HEALTH CARE WELFARE ASSOCIATION

Application form for Reimbursement

PART A: TO BE FILLED IN BY THE PATIENT/APPLICANT

Aadhaar Card No: Name of the Patient: Son/Daughter/Wife of: Date of Birth and Age: Mobile Number: Alternate Mobile Number: Address for Correspondence: PINCODE: Total Cost of Medical Expenses (Rs):

(B) The Patient is:

Live Dead

Live Patient Details:

Name of the Applicant: Applicant Aadhaar Card Number:

Deceased Patient Details:

Name of the Applicant: Relationship to the Patient: Birth/Death Certificate No.: Family Member Certificate No.: Applicant Aadhaar Card Number:

Name and Address of the Hospital where Treatment was Carried Out:

DECLARATION

I, am declaring with the above entered information is correct and complete in all aspects. I also declare that neither the patient nor the family claim prior, no assistance has been received. If any fraudulent information is provided, your application will be rejected..

Date: Place: Name/Signature of the Applicant:

List of Mandatory Enclosures:

Photo of the Patient/On-bed Photo Evidence for Treatment (Intra Operative Photo, Case Sheet) Copy of Aadhaar Card of the Patient/Applicant Mobile Number 1 Mobile Number 2 Copy of Lab/HPE/X-ray/CT/MRI Reports (Pre-treatment) Final Consolidated Bill (with Original Detailed Bills) Original Discharge Summary Copy of X-ray, Scan, Biopsy Reports (Post-treatment) Copy of Hospital Registration Certificate Copy of First Page of Bank Passbook Copy of Family Member Certificate (if deceased)

PART B: TO BE FILLED IN BY THE TREATING HOSPITAL

Name of the Patient: Son/Daughter/Wife of: Age and Sex: Patient Aadhaar No: OP/IP Number: Cost of the Treatment: Name of the Hospital & Address: Name of the Treating Doctor: Specialty: Phone: Email ID: Single Point of Contact with Hospital: Contact Number: Date: Place:

Checklist for Reimbursement:

Copy of Aadhaar Card Patient Mobile Number Alternate Mobile Number Copy of X-ray, Scan, Biopsy Reports Copy of Hospital Registration Certificate Final Bill with Signature and Stamp Original Discharge Summary Copy of First Page of Bank Pass Book

Enclosures Verification Remarks of Data Entry Operator: Name of the Volunteer: Signature of the Volunteer: Volunteer Number: