{"id":1001,"title":"Form for Request for Cashless Hospitalisation","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/Form_for_Request_for_Cashless_Hospitalisation_1_934a426ff9.pdf","sha256":"bbd6c4d468876be12c0fcf5957c91d60259d0b31f9fd49eeeed08e9f2bba98a7","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured patient or their representative to request cashless hospitalisation approval from the insurer or TPA. The hospital also fills part of the form and provides supporting documents.","notes":["Do not fax or scan page 2 of the form.","All original documents must be submitted; photocopies are not accepted.","Patient or representative must sign the declaration in presence of hospital staff.","Non-medical and non-covered expenses will be collected from the patient.","Discrepancies between this form and discharge summary may lead to non-payment.","Use block letters to fill the form."],"title":"Form for Request for Cashless Hospitalisation","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Patient and Hospitalisation Details","fields":[{"help":"Enter the full name of the insured patient","type":"text","label":"Patient’s / Insured’s Name:","options":[],"required":true,"pdf_field":"Insured_Name"},{"help":"Enter a valid phone number to contact the patient","type":"phone","label":"Contact number:","options":[],"required":true,"pdf_field":"Contact_No"},{"help":"Sign to confirm the information and declarations","type":"signature","label":"Patient’s / Insured’s Signature:","options":[],"required":true,"pdf_field":""}],"filled_by":"patient or insured"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"Agree to all declarations by checking","type":"checkbox","label":"Declaration by the Patient / Representative","options":["I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/T.P.A after the discharge.","I agree to sign on the Final Bill & the Discharge Summary, before my discharge.","Payment to hospital is governed by the terms and conditions of the policy.","I undertake to settle the bill if insurer/TPA is not liable.","I will pay all non-medical and non-covered expenses.","I declare to abide by the terms and conditions of the policy and indemnify insurer/TPA if facts are false.","I understand TPA does not guarantee hospital service quality.","I warrant the truth of all particulars and understand false statements will forfeit claim.","No benefits are admissible under any other medical scheme or insurance for this treatment.","I agree to indemnify the hospital against expenses not reimbursed by insurer/TPA."],"required":true,"pdf_field":""}],"filled_by":"patient or representative"},{"title":"Hospital Declaration","fields":[{"help":"Hospital to affix official seal","type":"signature","label":"Hospital Seal","options":[],"required":true,"pdf_field":""},{"help":"Attending doctor to sign","type":"signature","label":"Doctor's Signature","options":[],"required":true,"pdf_field":"Doctor_name"},{"help":"","type":"checkbox","label":"We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization.","options":["Agree"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient's discharge.","options":["Agree"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"We will abide by the terms and conditions agreed in the MOU.","options":["Agree"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Documents to be Provided by the Hospital in Support of the Claim","fields":[{"help":"Attach original discharge summary and hospital bills","type":"attachment","label":"Detailed Discharge Summary and all Bills from the hospital","options":[],"required":true,"pdf_field":""},{"help":"Attach original cash memos with prescriptions","type":"attachment","label":"Cash Memos from the Hospitals / Chemists supported by proper prescription.","options":[],"required":true,"pdf_field":""},{"help":"Attach original receipts and test reports with doctor's note","type":"attachment","label":"Receipts and Pathological Test Reports from Pathologists, supported by note from attending Medical Practitioner / Surgeon.","options":[],"required":true,"pdf_field":""},{"help":"Attach surgeon's certificate and bills","type":"attachment","label":"Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt.","options":[],"required":true,"pdf_field":""},{"help":"Attach cure certificates if available","type":"attachment","label":"Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured.","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient's discharge."],"applies_to":"Cashless hospitalisation requests under health insurance policies","attachments":["Detailed Discharge Summary and all Bills from the hospital","Cash Memos from the Hospitals / Chemists supported by proper prescription","Receipts and Pathological Test Reports from Pathologists, supported by note from attending Medical Practitioner / Surgeon","Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt","Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured"],"declarations":["Patient agrees to allow hospital to submit all original documents to Insurer/TPA after discharge.","Patient agrees to sign final bill and discharge summary before discharge.","Payment to hospital is governed by policy terms; patient will settle bill if insurer/TPA is not liable.","Patient will pay all non-medical and non-covered expenses.","Patient declares to abide by policy terms and indemnify insurer/TPA if facts are false.","TPA does not guarantee hospital service quality.","False or untrue statements will forfeit claim reimbursement.","No benefits are admissible under any other medical scheme or insurance for this treatment.","Patient agrees to indemnify hospital against expenses not reimbursed by insurer/TPA.","Hospital agrees to allow TPA/Insurance officials to verify documents.","Hospital agrees to send all valid original documents to TPA/Insurance within 7 days of discharge.","Hospital agrees to provide clarifications and take responsibility for delays.","Hospital agrees to abide by terms and conditions in the MOU."],"dropped_labels":1},"pdf_fields":[{"name":"Text1","page":1,"type":"text"},{"name":"Group2","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group2","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Text3","page":1,"type":"text"},{"name":"Text4","page":1,"type":"text"},{"name":"Text5","page":1,"type":"text"},{"name":"Text6","page":1,"type":"text"},{"name":"Text7","page":1,"type":"text"},{"name":"Text8","page":1,"type":"text"},{"name":"Check Box7","page":1,"type":"checkbox"},{"name":"Check 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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/1001-form-for-request-for-cashless-hospitalisation"}