{"id":1225,"title":"Pre-authorisation Form (STAR)","purpose":"claim","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/Preauthorisation_form_38c71d3dca.pdf","sha256":"b254b84bb47ae81e5ff5b2843b62d611fb45383cb4a88785ef3f50c1abbd8137","pages":7,"collected":"2026-10-20","instructions":{"about":"This form is for pre-authorisation of hospitalisation expenses under a health insurance policy and is filled by the policyholder and treating doctor/hospital.","notes":["Use original bills only.","Sign on the Final Bill and Discharge Summary before discharge.","Attach test reports if applicable.","PAN card or Form 60 copy is mandatory for KYC.","Fill dates in DD/MM/YYYY format.","Hospital seal must include Hospital Id."],"title":"Pre-authorisation Form (STAR)","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Patient and Policy Details","fields":[{"help":"","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"in years, months, days","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"To be filled by Treating Doctor / Hospital","fields":[{"help":"","type":"text","label":"Name of the treating Doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nature of illness/Disease with presenting complaint","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relevant Critical Findings","options":[],"required":true,"pdf_field":""},{"help":"Number of days","type":"number","label":"Duration of the present ailment (Days)","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of First consultation (DD/MM/YYYY)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Provisional diagnosis","options":[],"required":true,"pdf_field":""},{"help":"International Classification of Diseases code","type":"text","label":"ICD 10 code","options":[],"required":false,"pdf_field":""},{"help":"Select all applicable","type":"choice","label":"Proposed line of treatment","options":["Medical Management","Surgical Management","Intensive care","Investigation","Non-allopathic treatment"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If investigation and/or Medical Management, provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Route of Drug Administration","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If surgical, name of surgery","options":[],"required":false,"pdf_field":""},{"help":"Procedure Coding System code","type":"text","label":"ICD 10 PCS code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If other treatment, provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"How did injury occur","options":[],"required":false,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of injury","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Report to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"First Information Report number","type":"text","label":"FIR NO","options":[],"required":false,"pdf_field":""},{"help":"Attach test report if yes","type":"yes-no","label":"Test conducted to establish this (if yes, attach report)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Declaration by Treating Doctor and Hospital","fields":[{"help":"","type":"text","label":"Name of the treating doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Registration number with state code","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Hospital Seal (Must include Hospital Id)","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"","type":"signature","label":"Patient/Insured Name and Sign","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Time of signing","type":"text","label":"Time","options":[],"required":false,"pdf_field":""}],"filled_by":"patient or representative"},{"title":"Customer AML - KYC Addendum Form","fields":[{"help":"","type":"text","label":"Proposer Name - First Name","options":[],"required":true,"pdf_field":""},{"help":"Same as Proof of Address","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Current Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Tick if current address is same as permanent address","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin Code (Current Address)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Attach any one proof in support of ID and Address","options":["Voter ID","Driving License","Aadhar Card","Passport","NREGA Job Card","Any Govt. Notified Document"],"required":true,"pdf_field":""},{"help":"PAN card or Form 60 copy is mandatory","type":"text","label":"PAN Number or Form 60 Furnished","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Father / Spouse Name - First Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Mother Name - First Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Income Source","options":["Salary","Business","Others please specify"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"","attachments":["Test report if test conducted to establish substance abuse/alcohol consumption","Proof of ID and Address (one of Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card, Any Govt. Notified Document)","PAN card or Form 60 copy"],"declarations":["I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TPA after discharge.","I agree to sign on the Final Bill & the Discharge Summary before discharge.","Payment to hospital is governed by the terms and conditions of the policy.","If Insurer/TPA is not liable to settle the hospital bill, I undertake to settle the bill as per policy terms.","All non-medical expenses and expenses not relevant to current hospitalization and amounts over authorized limit will be paid by me.","I declare to abide by the terms and conditions of the policy and agree to indemnify Insurer/TPA if facts disclosed are false or incorrect.","I understand TPA does not warrant the hospital service quality or guarantee services provided.","I warrant the truth of the particulars and agree that false statements will forfeit my claim.","I agree to indemnify the hospital against expenses not reimbursed by Insurer/TPA.","I/We authorize Insurance Company/TPA to contact me/us through mobile/email for claim updates.","I authorize Star Health and Allied Insurance Co. Ltd and its representatives to seek medical information/records related to my treatment."],"dropped_labels":34},"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/star-health-and-allied-insurance/1225-pre-authorisation-form-star"}