{"id":1000,"title":"Claim Form Part-B To Be filled in by the Hospital","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/Claim_Form_Part_B_To_Be_filled_in_by_the_Hospital_04e739021a.pdf","sha256":"00e20fb2d551bf0618ea54329ad2cb1a8d8af3c944fb9017b89c86c71b034a88","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is to be filled by the hospital to provide detailed information about the hospital, patient admission, diagnosis, procedures, and claim documents for processing an insurance claim.","notes":["Use dd-mm-yy format for dates and hh:mm format for times.","Include STD codes with phone numbers.","Tick the appropriate options where indicated.","Fill all details accurately as per hospital and patient records."],"title":"Claim Form Part-B To Be filled in by the Hospital","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF HOSPITAL","fields":[{"help":"Enter the full name of the hospital","type":"text","label":"Name of Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital ID as allocated by the TPA","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Type of Hospital","options":["In network","Non network"],"required":null,"pdf_field":""},{"help":"Enter the full name of the treating doctor","type":"text","label":"Name of treating doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter abbreviations of educational qualifications","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number of the doctor with state code as allocated by Medical Council of India","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION B – DETAILS OF THE PATIENT ADMITTED","fields":[{"help":"Enter the full name of the patient","type":"text","label":"Name of Patient","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance provider registration number as allotted by the insurance provider","type":"text","label":"IP Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"text","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format for time of admission","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format for time of discharge","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Type of Admission","options":[],"required":null,"pdf_field":""},{"help":"Enter date of delivery if maternity case, use dd-mm-yy format","type":"date","label":"If Maternity Date of Delivery","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status if maternity case using standard format","type":"text","label":"Gravida Status","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Status at time of discharge","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY)","fields":[{"help":"Enter ICD 10 code and description of primary diagnosis","type":"text","label":"ICD 10 Code Primary Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 code and description of additional diagnosis","type":"text","label":"Additional Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 code and description of co-morbidities","type":"text","label":"Co-morbidities","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of first procedure","type":"text","label":"ICD 10 PCS Procedure 1","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of second procedure","type":"text","label":"Procedure 2","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of third procedure","type":"text","label":"Procedure 3","options":[],"required":null,"pdf_field":""},{"help":"Enter details of the procedure","type":"text","label":"Details of Procedure","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Present Ailment is a Complication of PED","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pre-authorization obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorization number as allotted by TPA","type":"text","label":"Pre-authorization Number","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorization","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the correct option for cause of injury","type":"choice","label":"Cause","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If injury due to substance abuse/alcohol consumption, test conducted to establish this","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Medico Legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported To Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number as issued by police authorities","type":"text","label":"FIR No.","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported to police, give reason","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION D – CLAIM DOCUMENTS SUBMITTED-CHECK LIST","fields":[{"help":"Indicate which supporting documents are submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION E – DETAILS IN CASE OF NON NETWORK HOSPITAL","fields":[{"help":"Enter full postal address including street, city and pin code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number as allocated by the hospital","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Enter permanent account number as allotted by Income Tax department","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of Inpatient Beds","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct options; if others, please specify","type":"choice","label":"Facilities available in the hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION F - DECLARATION BY THE INSURED","fields":[{"help":"Read declaration carefully, mention date (dd:mm:yy), place and sign","type":"signature","label":"Declaration by the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION G - DECLARATION BY THE HOSPITAL","fields":[{"help":"Read declaration carefully, mention date (dd:mm:yy), place, sign and stamp","type":"signature","label":"Declaration by the Hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["The insured must read and sign the declaration with date and place.","The hospital must read and sign the declaration with date, place and stamp."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/oriental-insurance/1000-claim-form-part-b-to-be-filled-in-by-the-hospital"}