MAHARASHTRA POLICY KUTUMB AROGYA YOJNA

Maharashtra Police: Desk No 28, Maharshtra Rajya Police

Mukhyalaya, S B Singh Marg, Colaba, Mumbai 400039

Initial Intimation Letter to be forwarded by Hospital to MAHS

Information to be filled in by the Member :

Name of Patient: Shri / Smt / Kumar / Kumari : Name of Employee : Shri / Smt.

Patient's UHID No.: MAHP Employee's UHID No.: MAHP

Age : Sex : Male / Female Basic Salary: Rs. Buckle No.:
Relation with Employee : Wife Working : Y/N Designation :
Apart from MPKAY Scheme Claiming from Place fo Working with Address :
any Insurance / Compay / Govt : Yes / No
If YES Name of Company : Personal / Residential Contact No. :
No. of Children :
Residential Address :

Information to be filled in by Treating Doctor / Hospital :

Name of the Hospital :

Date of Admission : Admission Under Dr.
Presenting Complaing :

History of Presenting Complaints :

Past History : HTN : DM : Others :

Clinical Findings :

Provisional / Differential Diagnosis :

Proposed line of Treatment :

In Case of RTA, please mention if the patient was under infulence of Alcohol / Drug and
send Attested MLC and FIR copy along with the Intimation letter

Approximate Duration of Stay : Approximate Expenses :

Class of Accommodation :
Treating Doctor's Name : Specialty : Registration No. :

Authorized Signatory :

Name & Designation :

Seal of the Hospital :