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Sie Labs - Insured Form

The document is a patient information form for insurance claims, requiring details such as patient name, age, insurance policy information, hospital admission dates, and medical history. It also includes sections for personal habits, previous hospitalizations, and a self-declaration by the patient. Additionally, there is a customer feedback section regarding the verification officer's conduct during the claims process.

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67 views

Sie Labs - Insured Form

The document is a patient information form for insurance claims, requiring details such as patient name, age, insurance policy information, hospital admission dates, and medical history. It also includes sections for personal habits, previous hospitalizations, and a self-declaration by the patient. Additionally, there is a customer feedback section regarding the verification officer's conduct during the claims process.

Uploaded by

DC Tech 2 sig
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SIELabs

To Be Filled By Patient / Insured


Name of Patient

Age

Claim Number

Name of insurance company

Policy Number

Type of Policy Group [ ] / Individual [ ]

Name of Proposer
Relation of Proposer with Insured person
Date of policy inception (Policy start date/year)
Address

Name of the admitting hospital

Date of admission & Date of Discharge & time


time
Symptoms /complaints /injury (circumstance of
injury)

Duration of these complaints

What was Diagnosis made by doctor in the


hospital?

History of similar complaints in past. If yes


provide details with the name of treating doctor

Was any other doctor consulted before visiting the


admitting hospital? Please provide details.

Do you have any other health policy if yes please


provide details

1
Signature of patient/ Insured
SIELabs
What is the occupation of the insured?

How far is the insured’s


residence from hospital?

Reason for selecting


this particular hospital

Are there any other good hospitals


in between the insured’s residence and the present
hospital where he was admitted?

Details of Family Physician / First Consulting Doctor

Apart from this existing policy, How many other policies


Does the insured have
- with us and
- with other insurers

Details of earlier claims availed from us and


Importantly from Other insurers?

Past medical history


YES NO DURATION CONSULTING
DOCTOR/HOSPITAL/CLINIC
DIABETES MELLITUS

HYPERTENSION/

DYSLIPIDEMIA
HYPERTHYROIDISM

HYPOTHYROIDISM

KIDNEY DISEASES/ KIDNEY STONE

HEART DISEASE

2
Signature of patient/ Insured
SIELabs
RESPIRATORY DISORDER/ASTHMA/COPD

OSTEOARTHRITIS/ARTHRITIS/ BONE & JOINT


RELATED PROBLEMS

LIVER DISEASE

GYNEAC RELATED PROBLEMS

IF ANY OTHER DISEASE PLEASE SPECIFY

3) Please give details of your previous hospitalization if any

Hospital name & DOA Complaint Treatment (medical/surgical)

4) Please give details of Personal habits/ addiction/ regular drugs if any with duration and
quantity.

Smoking – Alcohol -

Others- H/o of regular medication – yes/no

If yes details –

3
Signature of patient/ Insured
SIELabs
Self Declaration by patient

Patient Signature

Name

Place

5
Signature of patient/ Insured
SIELabs
Customer Feedback
INSUREANCE CO. NAME

Customer Name:

Address:

Email/Phone

Vendor Name

Name of Verification Officer

1. Did verification officer explain you the purpose of visit ?

2. Did he take consent for verification process ?

3. Did he present you authority letter/ Identity card ?

4. Was there any misbehavior/rude/arrogant behavior from verification officer during


verification ?

5. Did he take photographs of all the related documents, prescription, reports, and films with
willful consent

6. Was the information shared without any force, fear, influence or pressure and without
giving money or gift to the representative

7. Please give overall feedback,

Date Date
Signature of insured Signature of
verification officer
Contact No :

6
Signature of patient/ Insured

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