PRE – AUTHORIZATION FORM GOOD HEALTH

INSURANCE
REQUEST FOR CASHLESS HOSPITALIZATION FOR HEALTH INSURANCE POLICY TO BE FILLED IN BLOCK LETTERS
TPA LIMITED

Please fill all pages : This is Page 1 of 4

Tel : 1 8 6 0 4 2 5 3 2 3 2
Fax : 1 8 6 0 4 2 5 4 2 4 2
Email : p r e a u t h @ g h p l t p a . c o m
Web : www.goodhealthtpa.com
1 DETAILS OF THIRD PARTY ADMINISTRATOR AND HOSPITAL

NAME OF THE TPA G O O D H E A L T H I N S U R A N C E T P A L T D .

TOLL FREE PHONE NO. 1 8 0 0 4 2 5 3 2 3 2 TOLL FREE FAX NO. 1 8 6 0 4 2 5 4 2 4 2

HOSPITAL NAME

HOSPITAL LOCATION A R E A C I T Y

HOSPITAL ROHINI ID HOSPITAL TPA ID

HOSPITAL FAX NO. HOSPITAL PHONE NO.

HOSPITAL EMAIL ID

2 TO BE FILLED IN BY INSURED/PATIENT : DETAILS OF INSURED/PATIENT (Please also sign the declaration on last page of this form)

PATIENT NAME

GENDER MALE FEMALE THIRD GENDER AGE YEARS / MONTHS DATE OF BIRTH D D M M Y Y Y Y

CONTACT NO. CONTACT NO. OF ATTENDING RELATIVE

OCCUPATION TPA CARD ID

POLICY NO./CORPORATE NAME

EMPLOYEE ID

ADDRESS OF THE INSURED PATIENT

DO YOU HAVE ANY OTHER MEDICLAIM YES / NO

POLICY NO.

INSURANCE CO. NAME

DO YOU HAVE A FAMILY PHYSICIAN YES / NO

PHYSICIAN NAME

CONTACT NO.
PRE – AUTHORIZATION FORM GOOD HEALTH
INSURANCE
REQUEST FOR CASHLESS HOSPITALIZATION FOR HEALTH INSURANCE POLICY TO BE FILLED IN BLOCK LETTERS
TPA LIMITED

Please fill all pages : This is Page 2 of 4

Tel : 1 8 6 0 4 2 5 3 2 3 2
Fax : 1 8 6 0 4 2 5 4 2 4 2
Email : p r e a u t h @ g h p l t p a . c o m
Web : www.goodhealthtpa.com

3 TO BE FILLED IN BY TREATING DOCTOR / HOSPITAL (Please also sign the declaration on last page of this form)

TREATING DOCTOR NAME CONTACT NO.

NATURE OF RELEVANT CRITICAL

ILLNESS / DISEASE FINDINGS
WITH PRESENTING
COMPLAINT

PAST HISTORY OF DURATION OF PRESENT AILMENT DAYS

PRESENT AILMENT

DATE OF 1ST CONSULTATION D D M M Y Y Y Y

PROVISIONAL PROPOSED LINE MEDICAL MANAGEMENT

DIAGNOSIS OF TREATMENT SURGICAL MANAGEMENT
(PLS TICK) INTENSIVE CARE
INVESTIGATION
NON-ALLOPATHIC TREATMENT
ICD 10 CODE
PLEASE PROVIDE DETAILS OF (IF ANY)
INVESTIGATIONS MEDICAL MANAGEMENT NAME OF SURGERY OTHER TREATMENT

ROUTE OF DRUG
MANAGEMENT

ICD 10 PCS CODE

HOW DID INJURY OCCUR

IN CASE OF INJURY/DISEASE CAUSED

YES NO
ACCIDENT : IS IT RTA DUE TO SUBSTANCE
YES NO
ABUSE/ALCOHOL
REPORT TO POLICE YES NO CONSUMPTION
DATE OF INJURY D D M M Y Y Y Y TEST CONDUCTED TO
ESTABLISH THIS (IF YES, YES NO
FIR NO.
ATTACH REPORT)

IN CASE OF MATERNITY G P L A

EXPECTED DATE OF DELIVERY D D M M Y Y Y Y

 PRE – AUTHORIZATION FORM GOOD HEALTH
INSURANCE
REQUEST FOR CASHLESS HOSPITALIZATION FOR HEALTH INSURANCE POLICY TO BE FILLED IN BLOCK LETTERS
TPA LIMITED

Please fill all pages : This is Page 3 of 4

Tel : 1 8 6 0 4 2 5 3 2 3 2
Fax : 1 8 6 0 4 2 5 4 2 4 2
Email : p r e a u t h @ g h p l t p a . c o m
Web : www.goodhealthtpa.com

DETAILS OF PATIENT ADMITTED

DATE OF ADMISSION D D M M Y Y Y Y IS THIS AN EMERGENCY /

PLANNED HOSPITALIZATION
EMERGENCY PLANNED
TIME OF ADMISSION M M H H EVENT

EXPECTED NO. OF DAYS DAYS DAYS IN ICU DAYS

/ STAY IN HOSPITAL
ROOM TYPE
MANDATORY PAST HISTORY OF ANY CHRONIC ILLNES
COST IN INR / RS. IF YES, SINCE

PER DAY ROOM RENT + DIABETIES…………………………… M M Y Y Y Y

NURSING & SERVICE CHARGES ….
+ PATIENTS DIET
HEART DISEASE…………….………. M M Y Y Y Y
EXPECTED COST OF
INVESTIGATION + DIAGNOSTIC
HYPERTENSION…………………….. M M Y Y Y Y
ICU CHARGES

OT CHARGES HYPERLIPIDEMIAS….…………….. M M Y Y Y Y

PROFESSIONAL FEES SURGEON OSTEOARTHRITIS…...……………. M M Y Y Y Y

+ ANESTHETIC FEES +
CONSULTATION CHARGES
ASTHAMA/COPD/BRONCHITIS M M Y Y Y Y
MEDICINES + CONSUMABLES +
COST OF IMPLANTS (PLS
CANCER………………………………… M M Y Y Y Y
SPECIFY)

OTHER HOSPITAL EXPENSES, IF ALCOHOL/DRUG ABUSE…..…… M M Y Y Y Y

ANY
ANY HIV OR STD RELATED
ALL-INCLUSIVE PACKAGE
AILMENT………………………………. M M Y Y Y Y
CHARGES IF APPLICABLE
ANY OTHER AILMENT, GIVE
SUM-TOTAL EXPECTED COST DETAILS...……………………………… M M Y Y Y Y
OF HOSPITALIZATION

4 DECLARATION

WE CONFIRM HAVING READ, UNDERSTOOD AND AGREED TO THE DECLARATION OF THIS FORM

NAME OF THE TREATING DOCTOR

QUALIFICATION REGISTRATION NO. WITH STATE CODE

HOSPITAL SEAL PATIENT /

INCLUDING INSURED NAME
HOSPITAL ID AND SIGN
 PRE – AUTHORIZATION FORM GOOD HEALTH
INSURANCE
REQUEST FOR CASHLESS HOSPITALIZATION FOR HEALTH INSURANCE POLICY TO BE FILLED IN BLOCK LETTERS
TPA LIMITED

Please fill all pages : This is Page 4 of 4

Tel : 1 8 6 0 4 2 5 3 2 3 2
Fax : 1 8 6 0 4 2 5 4 2 4 2
Email : p r e a u t h @ g h p l t p a . c o m
Web : www.goodhealthtpa.com

DECLARATION BY THE PATIENT / REPRESENTATIVE :

a. 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.
b. Payment to the 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.
c. All non-medical expenses and expenses not relevant to current hospitalization and the amount over & above the limit
authorized by the Insurer / TPA not governed by the terms and conditions of the policy will be paid by me.
d. 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 Insurer / TPA.
e. 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.
f. 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.
g. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer /
TPA.
h. “I/We authorize Insurance Company / TPA to contact me / us through mobile / email for any update on this claim.”

a) Patient’s / Insured’s Name :_________________________________________________________________

b) Contact Number:__________________________________________________________________________

c) e-mail Id (Optional):________________________________________________________________________

d) Patient’s / Insured’s Signature:_______________________________________________________________

Date:__D D / M M / Y Y Y Y____ Time: ____H H / M M _____

HOSPITAL DECLARATION :
a. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to
hospitalization.
b. All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to the TPA
/ Insurance Company within 7 days of the patient’s discharge.
c. We agree that TPA / Insurance Company 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.
d. The patient declaration has been signed by the patient or by his representative in our presence.
e. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility
for any delay in offering clarifications.
f. We will abide by the terms and conditions agreed in the MOU.
g. We confirm that no additional amount shall be collected for the insured in excess of the Agreed Package Rates except
costs towards non-admissible amounts (including additional charges due to opting higher room rent than eligibility /
choosing separate line of treatment which is not envisaged / considered in package).
h. We confirm that no recoveries would be made from the deposit amount collected from the insured except for costs
towards non-admissible amounts (including additional charges due to opting higher room rent than eligibility / choosing
separate line of treatment which is not envisaged / considered in package).
i. In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed Package Rates, the
authorized TPA / Insurance Company reserves the right to recover the same from us (the Network Provider) and / or take
necessary action, as provided under the MOU or applicable laws.

HOSPITAL SEAL DOCTOR’S

INCLUDING NAME AND
HOSPITAL ID SIGN