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Dedicated Healthcare Services TPA (India) Private Limited (IRDA

License No.028)
Cambata Building (Eros Theatre Building), East Wing, 3rd Floor, 42, Maharshi Karve Road,
Churchgate Mumbai 400 020.

ADMISSION REQUEST FORM

_____________________________________________________________________
PART A-TO BE FILLED IN BY TREATING CONSULTANT
Date: _____________

Hospital Code: ________________ DHS ID. no.: ___________________ Employee ID no.:______________________


Name of Insured: _______________________________________________ Corporate Name:
_____________________________ _
Name of Insurance
Company:_______________________________________________
Name of Patient: Shri/Smt/Kum: _________________________________________________________Age: ______ Sex:
_________ Patients Contact Details: Tel No._____________________Mobile no. __________________Email id
__________________________ Name of Treating Doctor: ______________________________________________ Doctor
Contact No: ________________________ Name of Hospital / Nursing Home:
_____________________________________________Email id / Cont. No:___________________ Presenting Complaints:
_________________________________________________________________________________________ History & Duration
of presenting complaints:________________________________________________________________________
Relevant Clinical Findings:
_______________________________________________________________________________________
Past Medical or Surgical History of
Patient:__________________________________________________________________________
InvestigationReports(pls attachseparatesheet):_______________________________________________________
Provisional/Differential Diagnosis: ______________________________________________________________________
ProposedTreatmentPlan(pls attachseparatesheet): ___________________________________________________

Please attach copy of patient photo id and DHS id card copy with this form.
Particulars
Hypertension
IHD
Osteoarthritis
COPD/ Bronchial Asthma

Yes/ No

since when

Particulars
Diabetes

Yes/No
1

Since when
2

Heart Dieases(date of first episode)

Cancer
Alcohol / Drug abuse
5
6
Maternity cases: Gravida_____Para___Living____LMP______

Any other Chronic Disorder

In case of Accidents, influence of alcohol / any other drugs: Yes / No.


Whether MLC done: Yes / No (if yes, please attach copy of the same)
Particulars
Date of Admission(Probable exact)
Approximate duration of stay
Class of accommodation
Name of Implant
Cost of Implant
Approximate expenses

Details

Particulars
Room Rent+ Nursing Charges
Surgeon Fees
OT Charges/Anesthesia/Consumables
Doctor Consultation / Visits charges
Investigation charges
Medicines Charges
Total Amount
Service Tax
Grand Total

PARTB TO BE FILLED BY THE HOSPITAL AUTHORITIES


DHS will not be held liable for the payment in the event of any discrepancy between the facts presented at the time of
admission & in final documents submission.

Signature& Stampof TreatingDoctor: ________________ Stampof Hospital: ___________________________


Regn.No. of TreatingDoctor:_______________________
HospitalServiceTax Regn.No.:_____________________
HospitalAuthorizedSignatory: ________________
PARTC- TO BE FILLED UP BY THE PATIENT / INSURED
I have No Objection to DHS obtaining details of my treatment / collecting documents and also hereby authorize DHS to pay
the hospital bill & reimburse itself / receive the amount from my claim receivable from my insurance company. If my claim is
rejected, I/we (the patient) will pay for the hospital & related expenses, should this authorization become null & void, due to

wrong and/ or misleading and/or incorrect information regarding the duration of ailments and/or other historical information
regarding my (patients) health status/. I acknowledge and agree that information provided by me are true and up to the best
of my knowledge.
Previous policy details: Policy No.______________________________ Insurance Company: ________________________
Concurrent Policy details: ____________________________________ Contact Info: ______________________________
Signature. _______________________________ Name: ___________________________________________________