{"id":1006,"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_1_11fc51df77.pdf","sha256":"da5eef69bb015d26976b02699bf8df81f1c5f4af1ce6eab9a8116b897651294f","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for hospitals to fill in details related to a patient's hospitalisation and treatment for insurance claim processing.","notes":["Use dd-mm-yy format for dates unless otherwise specified.","Use hh:mm format for times.","Include STD code with phone numbers.","Tick the appropriate options where indicated.","Fill the form in block letters where applicable."],"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":"HID"},{"help":"Tick the correct option","type":"choice","label":"Type of Hospital","options":["In network","Non network"],"required":null,"pdf_field":"Check Box3"},{"help":"Enter the full name of the treating doctor","type":"text","label":"Name of treating doctor","options":[],"required":null,"pdf_field":"PRO1"},{"help":"Enter abbreviations of educational qualifications","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":"Qualification"},{"help":"Enter registration number of doctor with state code as per Medical Council of India","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":"RNO"},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":"PHONE"}],"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":"PNO"},{"help":"Enter insurance provider registration number","type":"text","label":"IP Registration Number","options":[],"required":null,"pdf_field":"IP Reg No"},{"help":"Tick Male or Female","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":"Group4"},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":"Years"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":"DOA"},{"help":"Use hh:mm format for time of admission","type":"text","label":"Time","options":[],"required":null,"pdf_field":"TIME1"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":"DOD"},{"help":"Use hh:mm format for time of discharge","type":"text","label":"Time","options":[],"required":null,"pdf_field":"TIME2"},{"help":"Tick the correct option","type":"choice","label":"Type of Admission","options":[],"required":null,"pdf_field":"Group5"},{"help":"If maternity, enter date of delivery in dd-mm-yy format","type":"date","label":"Date of Delivery","options":[],"required":false,"pdf_field":"DODL"},{"help":"If maternity, enter gravida status","type":"text","label":"Gravida Status","options":[],"required":false,"pdf_field":"GRAVIDA"},{"help":"Tick the correct option","type":"choice","label":"Status at time of discharge","options":[],"required":null,"pdf_field":"status_d"}],"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":"PD"},{"help":"Enter ICD 10 code and description of additional diagnosis","type":"text","label":"Additional Diagnosis","options":[],"required":false,"pdf_field":"COM"},{"help":"Enter ICD 10 code and description of co-morbidities","type":"text","label":"Co-morbidities","options":[],"required":false,"pdf_field":"COM1"},{"help":"Enter ICD 10 PCS code and description of first procedure","type":"text","label":"ICD 10 PCS - Procedure 1","options":[],"required":false,"pdf_field":"PRO2"},{"help":"Enter ICD 10 PCS code and description of second procedure","type":"text","label":"Procedure 2","options":[],"required":false,"pdf_field":"PRO3"},{"help":"Enter ICD 10 PCS code and description of third procedure","type":"text","label":"Procedure 3","options":[],"required":false,"pdf_field":"COMD1"},{"help":"Enter details of the procedure","type":"text","label":"Details of Procedure","options":[],"required":false,"pdf_field":"COMD2"},{"help":"Tick Yes or No","type":"yes-no","label":"Present Ailment is a Complication of PED","options":["Yes","No"],"required":null,"pdf_field":"Check Box6"},{"help":"Tick Yes or No","type":"yes-no","label":"Pre-authorization obtained","options":["Yes","No"],"required":null,"pdf_field":"Check Box7"},{"help":"Enter pre-authorization number allotted by TPA","type":"text","label":"Pre-authorization Number","options":[],"required":false,"pdf_field":"PDD"},{"help":"Enter reason for not obtaining pre-authorization","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":"reason"},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":"Check Box8"},{"help":"Tick the correct cause of injury","type":"choice","label":"Cause","options":[],"required":false,"pdf_field":"Group9"},{"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":false,"pdf_field":"Check Box9"},{"help":"Tick Yes or No","type":"yes-no","label":"Medico Legal","options":["Yes","No"],"required":null,"pdf_field":"Check Box10"},{"help":"Tick Yes or No","type":"yes-no","label":"Reported To Police","options":["Yes","No"],"required":null,"pdf_field":"Check Box11"},{"help":"Enter FIR number issued by police authorities","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":"FIR"},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported to police, give reason","options":[],"required":false,"pdf_field":"OTHERS"}],"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":"ADD1"},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":"PHONE"},{"help":"Enter registration number as allocated by hospital","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":"REG NO"},{"help":"Enter permanent account number allotted by Income Tax department","type":"text","label":"PAN","options":[],"required":null,"pdf_field":"PAN"},{"help":"Enter number of inpatient beds","type":"number","label":"Number of Inpatient Beds","options":[],"required":null,"pdf_field":"NOB"},{"help":"Tick the correct options; if others, specify","type":"choice","label":"Facilities available in the hospital","options":[],"required":null,"pdf_field":"Group10"}],"filled_by":"hospital"},{"title":"Section F - Declaration by the Insured","fields":[{"help":"Enter date in dd:mm:yy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":"DATE"},{"help":"Enter place","type":"text","label":"Place","options":[],"required":null,"pdf_field":"PLACE"}],"filled_by":"insured"},{"title":"Section G - Declaration by the Hospital","fields":[{"help":"Enter date in dd:mm:yy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":"DATE"},{"help":"Enter place","type":"text","label":"Place","options":[],"required":null,"pdf_field":"PLACE"}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"","attachments":["Supporting documents as per checklist in Section D"],"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":2},"pdf_fields":[{"name":"NOH","page":1,"type":"text"},{"name":"HID","page":1,"type":"text"},{"name":"Check Box3","page":1,"type":"checkbox"},{"name":"Check Box4","page":1,"type":"checkbox"},{"name":"NOD","page":1,"type":"text"},{"name":"Qualification","page":1,"type":"text"},{"name":"RNO","page":1,"type":"text"},{"name":"PNO","page":1,"type":"text"},{"name":"IP Reg No","page":1,"type":"text"},{"name":"NOP","page":1,"type":"text"},{"name":"Group4","page":1,"type":"radiobutton","options":["Choice1","Choice2","Choice1","Choice2"]},{"name":"Years","page":1,"type":"text"},{"name":"Months","page":1,"type":"text"},{"name":"DOB","page":1,"type":"text"},{"name":"DOA","page":1,"type":"text"},{"name":"TIME1","page":1,"type":"text"},{"name":"status_d","page":1,"type":"text"},{"name":"TIME2","page":1,"type":"text"},{"name":"DOD","page":1,"type":"text"},{"name":"Check Box6","page":1,"type":"checkbox"},{"name":"Check Box7","page":1,"type":"checkbox"},{"name":"Check Box8","page":1,"type":"checkbox"},{"name":"Check Box9","page":1,"type":"checkbox"},{"name":"PDD","page":1,"type":"text"},{"name":"PDD1","page":1,"type":"text"},{"name":"Check Box11","page":1,"type":"checkbox"},{"name":"DODL","page":1,"type":"text"},{"name":"GRAVIDA","page":1,"type":"text"},{"name":"Check Box10","page":1,"type":"checkbox"},{"name":"Check Box12","page":1,"type":"checkbox"},{"name":"PD","page":1,"type":"text"},{"name":"PRO1","page":1,"type":"text"},{"name":"AD","page":1,"type":"text"},{"name":"Group4","page":1,"type":"radiobutton","options":["Choice1","Choice2","Choice1","Choice2"]},{"name":"Group4","page":1,"type":"radiobutton","options":["Choice1","Choice2","Choice1","Choice2"]},{"name":"ADD","page":1,"type":"text"},{"name":"PDD2","page":1,"type":"text"},{"name":"COMD1","page":1,"type":"text"},{"name":"Group5","page":1,"type":"radiobutton","options":["4","4","4"]},{"name":"PRO2","page":1,"type":"text"},{"name":"PRO3","page":1,"type":"text"},{"name":"COM","page":1,"type":"text"},{"name":"PDD3","page":1,"type":"text"},{"name":"COM1","page":1,"type":"text"},{"name":"DOP","page":1,"type":"text"},{"name":"Check Box13","page":1,"type":"checkbox"},{"name":"Check Box14","page":1,"type":"checkbox"},{"name":"COMD2","page":1,"type":"text"},{"name":"Text15","page":1,"type":"text"},{"name":"Check 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NO","page":1,"type":"text"},{"name":"PAN","page":1,"type":"text"},{"name":"NOB","page":1,"type":"text"},{"name":"Group9","page":1,"type":"radiobutton"},{"name":"Group9","page":1,"type":"radiobutton"},{"name":"Group10","page":1,"type":"radiobutton"},{"name":"Group10","page":1,"type":"radiobutton"},{"name":"OTHERS","page":1,"type":"text"},{"name":"DATE","page":1,"type":"text"},{"name":"PLACE","page":1,"type":"text"},{"name":"Signature of the insured","page":1,"type":"signature","label":"Signature of the insured"},{"name":"Print","page":2,"type":"button"}],"fillable_pdf":true,"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/1006-claim-form-part-b-to-be-filled-in-by-the-hospital"}