FHPL-PA-FT-02

Authorization Letter
Authorization Letter to the Hospital for the Treatment and Guarantee of Payment Valid for Admission
before 26 Jul 2019.

To, Date : 20/07/2019

Kanpur Medical Centre Pvt Ltd PA.No : 1160849/1
120/500(24), Lajpat Nagar,
Kanpur

Organisation Name : Abbott India Ltd : Parents

We are in receipt of the Admission / Pre Authorization request note with the following information :

Name of the patient Subhash Chandra UHID No OIC.21235820

Age 57 Years Gender Male
Room Board Category under General For(Ailment) GI Bleeding with cryptogenic CLD with
Portal Hypertension
We hereby authorize and guarantee for Payment up to (in figures) Rs. 10000.00/-
(In Words) Ten Thousand Only
The Probable Date of Admission is 19/07/2019

Hospital Alert

1) If the hospital bill is estimated to be higher that the guarantee of payment, a request letter for additional amount needs to be sent to us. If no further
guarantee is available, the hospital must collect the excess amount directly from the beneficiary at the time of admission / prior to discharge from the
Hospital, as per Hospital Rules and Regulations.
2) FHPL will not be liable for payment to the Hospital in the event of the facts presented by the Hospital / Insued during the preauthorization are
found to be incorrect/revised.
3) The Claim settlement would be as per the Tariff Discounts contracted in the Network agreement.

4) Please ensure to collect the charges pertaining to non-payable items. Please visit www.fhpl.net for list of non-payable items.
5)Please ensure to collect Copayment Rs. 0 from the member.

Doctors Note :
covered for medical management. Admission only for investigation and evaluation is not payable. Room Rent limit restricted to 2000/-for
Normal and 4000/-for ICU. All other related charges in accordance with room rent restriction or actual whichever is lower. In the event of a
person getting admitted in higher category, the related charges will be pro-rated to the eligibility limit as per the room rent restriction. All
other related charges will among other things include OT charges, doctor charges & Nursing charges &the same will be payable as per the
room rent entitlement.
.

For Billing : Please send the following Documents Within 2 days from the discharge of patient.
1) Enclose Photo ID card copy of the patient. 2) ARN(Admission Request Note). 3) Approval copy.
4) Hosp.bill summary with final bill showing details of units of each service(Authenticated by the patients signature.)
5) Discharge summary and reports of all Investigations(Original),prescription of Medicines.
6) The Above payment is subject to applicable TDS. 7) Enclose a copy of receipt given to patient for the amount paid by him.

8) Claim form of The Oriental Insurance Co. Ltd

9) GIPSA declaration form on the hospital letter head filled by the patient/patient’s attendants.

Dr.Monika Yadav
Authorized By Date : 7/20/2019 1:56:41 PM

Disclaimer:The cashless access in FHPL network of Hospitals merely a facility extended by your health coverage payer. FHPL/Payer does not
guarantee the availability, quality & outcome of the treatment. Choosing of a network or a non-network hospital is prerogative of the patient/Insured.

Please note that Admission only for investigations and evaluations are not payable

Undertaking by the patient

I authorize the hospital/provider to submit the attested Indoor Case Papers(Case Sheet) & any other documents/information related to my treatement
to FHPL If ask for.

Important: Please note that as stipulated by IRDAI all Network Providers should mandatorily register themselves with the Hospital Register

“ROHINI” maintained by the Insurance Information Bureau (IIB), unless which the Hospitals cannot be a part of the network and Cashless

Facility also cannot be extended to the Un-Registered Hospitals. You are hence requested to log on to https://rohini.iib.gov.in/ and

complete the Registration at the earliest. Please ignore if you have already registered.

Signature of the Patient/Insured

Family Health Plan Insurance TPA Ltd,Srinilaya - Cyber Spazio,Suite # 101,102,109 & 110,Ground Floor,Road No.2,Banjara Hills,Hyderabad-500 034.