MDINDIA HEALTHCARE SERVICES (TPA) PVT.LTD.

Head Office: MDIndia House, S No. 147/8, Near Kothrud Petrol Pump, Karve Statue Circle, Kothrud, Pune 411038

PRE-AUTHORISATION REQUEST FORM

[ ONLY FOR FUTURE GENERALI INDIA INSURANCE COMPANY LIMITED ] Fax No: 020-25300030 Cashless Toll Free No: 1800 233 4505 Customer Care Toll Free No: 1800 233 1166 Toll Free Fax No: 1800 233 4505 Cashless Mobile No: 09326442922 Email ID: authorisation@mdindia.com

Name of employee/proposer Name of patient Group/Company Name of the employee Employee No Mobile Communication Address Name of the Insurance Company Name of treating physician Qualification Name of hospital Hospital registration no. Hosp.Tel. no. Detailed diagnosis 1 Symptoms on admission Date of first onset of symptoms LMP / / EDD /

MDI ID No Relation Tel No

Age

Yrs

Details of treating physician and hospital

Mobile Reg. no Tel. Clinic Location Hosp. Fax no

Details of diagnosis
2 3 Date of first diagnosis

For Maternity
/ Obstetric History

L A
Yes / No

Indication for LSCS

For RTA
H/O Alcohol during accident Yes/No Date of admission Inject. () Expected length of stay Oral () Steroids Nutrients Sedatives Diuretics GI drugs MLC/FIR done for RTA

Treatment proposed (Please tick () where applicable)

Inject. () Antibiotics Anti-inflam. Drugs Neuro-musc. Drugs Cardiac Drugs Respiratory Drugs Other* (please specify) Investigations (enlist) Procedures /Surgical treatment (describe) Anesthesia GA / SA / LA / OTHERS* (please specify) Less than 24 hrs. Yes / No Oral () IV transfusions Chemotherapy Radiation Blood & comp. Continuous traction ()

Past History (Please specify duration)

Since Hypertension Dyslipidaemia Diabetes Personal H/O: Alcohol/Tobacco/Drug abuse Room rent / day Investigations Consumables Rs. Rs. Rs. (Please provide details for below if applicable) H/O surgery H/O similar/related complaints H/O of any cardiac ailment Since

Estimate of expenses (Room category general ward/twin sharing/single non ac/single ac/deluxe/suite)
Pharmacy Physician charge Other Rs. Rs. Rs. Surgeon charge Anesthetist charge TOTAL Rs. Rs. Rs.

*FOR RTA CASES MLC/FIR IS MANDATORY

DECLARATION: I hereby declare that the information provided in the form is true to the best of my knowledge, and authorize MDIndia Healthcare to seek any further information from the treating doctor / hospital if needed I undertake that if cashless facility is availed, all original documents, including the discharge summary and investigation reports shall be handed over to the hospital at the time of discharge along with the signed claim form. I am aware that without these documents the claim cannot be processed and I am liable for the same I am aware of my health insurance cover and if the hospital expenses exceed the amount, I shall be liable to pay the remainder of the amount at the time of discharge I undertake to pay all non-medical expenses incurred in the hospital at the time of discharge If the hospitalization comes under any of the policy exclusions & should this authorization become null and void due to wrong and/or misleading and/or incorrect information & is not reimbursed by the insurance company, I undertake to pay the amount to MDIndia Healthcare who have kindly extended credit facility to the hospital.

*FOR CATARACT CASES TYPE & COST OF LENS IS MANDATORY

Date _______________ Employee Signature ___________________________Mobile No _________________________________________ As treating physician, I hereby declare that the medical information declared in the form is true & accurate to the best of my knowledge. Date _______________ Hospital Stamp & Treating Physician Signature___________________ _Mobile No _________________________