{"id":1182,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICAL INSURANCE POLICY","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/health-form/Health_Pre_Authorization.pdf","sha256":"cc33656af2bf4a5c32b24f630cccff85a9bc20e49d983b586cc790b532b2c0a1","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for requesting cashless hospitalisation under a medical insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Use CAPITAL letters to fill hospital details","Attach original documents as per checklist","Submit page 1 only by fax/scan initially","Submit original documents within 7 days of discharge","KYC documents required for claims Rs. 1 Lakh and above","Hospital seal must include Hospital ID","Patient/Insured and doctor signatures required on declarations"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICAL INSURANCE POLICY","submit":{"to":"TPA / Insurance Company","how":"FAX/SCAN PAGE 1 ONLY as instructed; original documents to be sent within 7 days of discharge","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator","fields":[{"help":"","type":"text","label":"a) Name of the TPA/Insurance Company:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"b) Toll free Customer Helpline number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"c) Toll free FAX/ Email:","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"To be filled by Insured/Patient","fields":[{"help":"First Name, Middle Name, Last Name","type":"text","label":"a) Name of the Patient:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"b) Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Years and Months","type":"number","label":"c) Age:","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"d) Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"e) Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"g) Insured/Patient/Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"j) Insured Member ID card No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"k) Policy No./Corporate Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"m) Employee ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"o) Company Name:","options":[],"required":null,"pdf_field":""},{"help":"Details of Mediclaim/Health Insurance if any","type":"text","label":"p) Give details:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"q) Do you have a family physician:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"r) Name of the family physician:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"s) Contact No, if any","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/patient"},{"title":"To be filled by Treating Doctor/Hospital","fields":[{"help":"","type":"text","label":"a) Name of the Treating Doctor:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"b) Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"c) Nature of illness/ Disease with presenting complaints","options":[],"required":null,"pdf_field":""},{"help":"Days","type":"number","label":"e) Duration of present ailment:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"g) Past history of present ailment, if any","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"h) Provisional Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"International Classification of Diseases code","type":"text","label":"I) ICD Code:","options":[],"required":null,"pdf_field":""},{"help":"Select all applicable","type":"choice","label":"j) Proposed line of treatment","options":["Medical Management","Surgical Management","Intensive Care Unit","Investigation","Non allopathic treatment"],"required":null,"pdf_field":""},{"help":"Details of investigations or medical management","type":"text","label":"k) Investigational &/or Medical Management provide details","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"m) Route of drug administration","options":[],"required":null,"pdf_field":""},{"help":"Name of surgery if applicable","type":"text","label":"n) If surgical name of surgery","options":[],"required":null,"pdf_field":""},{"help":"Procedure Coding System code","type":"text","label":"o) ICD 10 PCS code","options":[],"required":null,"pdf_field":""},{"help":"Details of other treatments if any","type":"text","label":"p) If other treatment provide details","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"q) How did injury occur","options":[],"required":null,"pdf_field":""},{"help":"Subfields below","type":"section","label":"r) In case of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Road Traffic Accident","type":"yes-no","label":"I. Is RTA:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"ii. Date of injury:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"iii. Reported to police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"First Information Report number if applicable","type":"text","label":"iv. FIR No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"v) Injury/Disease caused due to substance abuse/alcohol consumption:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, attach report","type":"yes-no","label":"vi) Test conducted to establish this:","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Details of Patient Admitted","fields":[{"help":"DD/MM/YYYY","type":"date","label":"a) Date of admission:","options":[],"required":true,"pdf_field":""},{"help":"HH:MM","type":"text","label":"b) Time of admission:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"c) Is this a emergency/a planned hospitalisation event?:","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Number of days","type":"number","label":"d) Expected No. of days stay in hospital:","options":[],"required":true,"pdf_field":""},{"help":"Type of room","type":"text","label":"e) Room Type","options":[],"required":true,"pdf_field":""},{"help":"Amount in Rs.","type":"amount","label":"f) Per Day Room Rent + Nursing & Service Charges + Patient's Diet","options":[],"required":true,"pdf_field":""},{"help":"Amount in Rs.","type":"amount","label":"g) Expected cost for investigation + diagnostics","options":[],"required":true,"pdf_field":""},{"help":"Amount in Rs.","type":"amount","label":"h) ICU Charges","options":[],"required":true,"pdf_field":""},{"help":"Operation Theatre charges in Rs.","type":"amount","label":"I) OT Charges","options":[],"required":true,"pdf_field":""},{"help":"Amount in Rs.","type":"amount","label":"j) Professional fees Surgeon + Anesthetist Fees + consultation Charges","options":[],"required":true,"pdf_field":""},{"help":"Amount in Rs.","type":"amount","label":"k) Medicines + Consumables + Cost of Implants (if applicable please specify). Other hospital expenses if any","options":[],"required":true,"pdf_field":""},{"help":"Amount in Rs.","type":"amount","label":"l) All inclusive package charges if any applicable","options":[],"required":true,"pdf_field":""},{"help":"Total amount in Rs.","type":"amount","label":"m) Sum Total expected cost of hospitalization","options":[],"required":true,"pdf_field":""},{"help":"Specify illness and duration","type":"text","label":"MANDATORY: Past history of any chronic illness If yes, since (month/year)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Any other Ailment give details:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Hospital Details","fields":[{"help":"Fill in CAPITAL letters","type":"text","label":"a) Name :","options":[],"required":true,"pdf_field":""},{"help":"Fill in CAPITAL letters","type":"text","label":"b) Address:","options":[],"required":true,"pdf_field":""},{"help":"Fill in CAPITAL letters","type":"text","label":"c) Rohini ID:","options":[],"required":true,"pdf_field":""},{"help":"Fill in CAPITAL letters","type":"email","label":"d) Email ID:","options":[],"required":true,"pdf_field":""},{"help":"Fill in CAPITAL letters","type":"text","label":"f) Occupation:","options":[],"required":true,"pdf_field":""},{"help":"Fill in CAPITAL letters","type":"email","label":"h) Insured/Patient Email ID:","options":[],"required":true,"pdf_field":""},{"help":"Fill in CAPITAL letters","type":"phone","label":"I) Contact number of attending relative:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"","type":"text","label":"Patient's/ Insured's Name:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact No.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Patient's/ Insured's Signature:","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"a) Date:","options":[],"required":true,"pdf_field":""},{"help":"HH:MM","type":"text","label":"b) Time:","options":[],"required":true,"pdf_field":""}],"filled_by":"patient/insured or representative"},{"title":"Hospital Declaration","fields":[{"help":"","type":"signature","label":"Hospital Seal (Must include Hospital ID)","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Doctor’s Signature","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"a) Date:","options":[],"required":true,"pdf_field":""},{"help":"HH:MM","type":"text","label":"b) Time:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by Treating Doctor","fields":[{"help":"First Name, Middle Name, Last Name","type":"text","label":"a) Name of the treating doctor :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"c) Registration No. with state code:","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Annexure for Pre-Authorization Claims","fields":[{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Fill name, age, residence, and doctor details","type":"text","label":"I, Mr./Ms ___________________________________________________ Age ____________________ Resident of ______________________________________________________________ State _______________ Hereby give my willful consent to Mr/ Dr _______________________________________________ of Shriram General Insurance Company Limited to verify and collect necessary documents/ statements including but not limited to certified copies of medical records from your esteemed hospital for the purpose of settlement of my Insurance claim.","options":[],"required":null,"pdf_field":""},{"help":"Provide insured details below","type":"text","label":"Detail of Insured:-","options":[],"required":null,"pdf_field":""},{"help":"Date of Admission","type":"text","label":"DOA:-","options":[],"required":null,"pdf_field":""},{"help":"Date of Discharge","type":"text","label":"DOD:-","options":[],"required":null,"pdf_field":""},{"help":"Medical Record Number or IP number","type":"text","label":"MRD/ Indoor/ IP No:-","options":[],"required":null,"pdf_field":""},{"help":"Policy Number","type":"text","label":"Policy No:-","options":[],"required":null,"pdf_field":""},{"help":"Name of insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Signature or thumb impression of insured","type":"signature","label":"Signature/ Thumb Impression","options":[],"required":null,"pdf_field":""},{"help":"Name and signature of witness","type":"signature","label":"Witness Name & Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/patient"},{"title":"Document Checklist","fields":[{"help":"Valid KYC documents such as PAN Card, Driving License, Voter ID Card, Aadhar Card","type":"attachment","label":"I. Copy of Photo ID, address proof and recent photo of patient.","options":[],"required":true,"pdf_field":""},{"help":"","type":"attachment","label":"II. Past illness records (With duration of symptoms) if any","options":[],"required":null,"pdf_field":""},{"help":"","type":"attachment","label":"III. First and subsequent consultation paper along with admission note.","options":[],"required":null,"pdf_field":""},{"help":"","type":"attachment","label":"IV. Complete medical history along with supporting investigation reports.","options":[],"required":null,"pdf_field":""},{"help":"Medico Legal Certificate / FIR copy if applicable","type":"attachment","label":"V. In case of accident, MLC/FIR copy (if applicable)","options":[],"required":null,"pdf_field":""},{"help":"","type":"attachment","label":"VI. Claim consent letter","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/patient"}],"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 for medical insurance policies","attachments":["Original copy of detailed Discharge Summary and all Bills from the hospital","Original copy of cash Memos from the Hospitals / Chemists supported by prescription","Original copy of receipts, Investigation Reports and Radiological Films, supported by note from the attending Medical Practitioner/ Surgeon recommending such investigations","Original copy of surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt","KYC documents (Driving License / AADHAR Card / Voter Card / Passport / any other Government authorised identity proof of the insured carrying name and photograph)"],"declarations":["I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TPA after discharge and to sign the final bill and discharge summary","Payment to hospital is governed by the terms and conditions of the policy; if insurer/TPA is not liable, I will settle the bill","Non-medical and non-relevant expenses and amounts over authorized limits will be paid by me","I declare to abide by the policy terms and if any facts are false or incorrect, I forfeit my claim and indemnify the insurer/TPA","TPA does not guarantee the quality or standard of hospital services","False or untrue statements or concealment will forfeit my right to claim reimbursement","I agree to indemnify the hospital against expenses not reimbursed by insurer/TPA","I authorize Insurance Company TPA to contact me through mobile/email for claim updates","Hospital agrees to provide clarifications and abide by terms and conditions of the MOU","Hospital confirms no additional amount will be collected from insured beyond agreed package rates except non-admissible amounts","Hospital confirms no recoveries will be made from deposit except for non-admissible amounts","Unauthorized recovery of additional amounts may be recovered by TPA/Insurance Company from hospital or action taken","I hereby understand, declare, consent and authorize the company to use and retain my personal health, medical history and financial information for claim processing and insurance services"],"dropped_labels":5},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"chd@shriramgi.com","label":"Help Desk Email ID for claim intimation","level":null,"hours":null,"applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ase download the CLAIM INTIMATION SHEET, fill it and send it to our Help\n                            Desk via Email ID (chd@shriramgi.com)\nNote:\nPlease ensure that the following information is ready with you at the time of\n                            claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-300-30000","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 4:00 AM to Midnight 12:00","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"Option 1:\nIntimate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-3009","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 9:30 am to 5:30 pm","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our Help","fetched_at":"2026-10-20"}],"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/shriram-general-insurance/1182-request-for-cashless-hospitalisation-for-medical-insurance-policy"}