| Patient Name* |
|
Intimation Date* |
|
| Hospital Name* |
Hospital Not In System
Hospital Address
|
|
Hospital Type*
|
|
| PPN / Non PPN* |
PPN
Non PPN
|
|
Yes
No
PPN And Network Both
Non PPN And Non Network
|
| Contact No |
|
Email ID |
|
| Date of Admission* |
|
Time of Admission (Time Format-HH:MM) |
Hrs
Min
|
Expected No of days stay in hospital* |
Days
|
Time of Discharge (Time Format-HH:MM) |
Hrs
Min
|
|
|
Proposed line of treatment*
( Required Note : Please select either Medical Management Or Surgical Management. )
|
Medical Management
Surgical Management
Intensive Care
Investigation
Non Allopathic Treatment
|
Intimation Letter/Email pdf |
|
| Nature of the illness/disease with presenting complaints |
|
| Services |
Amount Breakup(Calculation) |
Request Amount |
| Total Requested Amount* |
|
|
|
