{"id":124,"title":"Treating Hospital Certificate (Form – H)","purpose":"claim","insurer":{"slug":"canara-hsbc-life-insurance","name":"Canara HSBC Life Insurance Company Limited"},"source_pdf":"https://www.canarahsbclife.com/content/dam/chli/pdf/document-component/individual-claims/english/treating-hospital-certificate.pdf","sha256":"8ae8d256fc5da00fce56e23388b10a20836c3b6d5b0bcbcae1a5babf853899df","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is to be completed by the authorities at the hospitals where the deceased was hospitalized to provide medical details for insurance claim purposes.","notes":["One form to be filled per hospital/nursing home","Attach all supporting medical documents","Hospital seal/stamp is mandatory"],"title":"Treating Hospital Certificate (Form – H)","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Deceased and Hospitalization Details","fields":[{"help":"","type":"text","label":"Policy no(s)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of the deceased","options":[],"required":null,"pdf_field":""},{"help":"Write age in years and occupation","type":"text","label":"Age at Death years, Occupation","options":[],"required":null,"pdf_field":""},{"help":"Describe any identification marks","type":"text","label":"Any mark of identification?","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time of death","type":"date","label":"Date of Death       /        /        Time of Death :                (a.m. / p.m. )","options":[],"required":null,"pdf_field":""},{"help":"Specify place of death","type":"text","label":"Place of Death","options":[],"required":null,"pdf_field":""},{"help":"Provide admission date, time and admission number","type":"date","label":"Date and Time of admission       /        /       ;      : (a.m. / p.m. ) Admission no.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the deceased referred by any doctor/ hospital        Yes      No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide name and address of referring doctor/hospital if applicable","type":"text","label":"If yes, then provide with the name and address","options":[],"required":null,"pdf_field":""},{"help":"Provide contact number of referring doctor/hospital","type":"phone","label":"Contact no.","options":[],"required":null,"pdf_field":""},{"help":"Describe complaints or condition at admission","type":"text","label":"What were the complaints/ condition of the deceased at the time of admission?","options":[],"required":null,"pdf_field":""},{"help":"Describe illness nature and duration","type":"text","label":"What was the exact nature and duration of the illness suffered by the deceased ? (Please enclose admission notes)","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the history of illness reported by the patient himself?      Yes     No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide name of person who reported history if not patient","type":"text","label":"If no, then by whom the history was reported","options":[],"required":null,"pdf_field":""},{"help":"Provide doctor's name who recorded history","type":"text","label":"Name of the doctor who had recorded the history in the records","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Did the deceased suffer from any past ailment as disclosed at the time of admission?      Yes     No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe past ailment and duration","type":"text","label":"If yes, then provide details of the nature of the ailment and its duration","options":[],"required":null,"pdf_field":""},{"help":"Provide diagnosis details","type":"text","label":"What was the diagnosis made at the hospital","options":[],"required":null,"pdf_field":""},{"help":"List tests and investigations done","type":"text","label":"What were the tests/ investigations undergone by the deceased at the hospital to confirm the diagnosis? (Please attach separate sheets if required)","options":[],"required":null,"pdf_field":""},{"help":"Provide date/time diagnosis was confirmed","type":"text","label":"When was the diagnosis confirmed at the hospital?","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital authorities"},{"title":"Treatment and Other Medical Details","fields":[{"help":"Describe treatment provided","type":"text","label":"What was the treatment given to the deceased during the hospitalization?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was/ were there any other contributory illnesses/ chronic ailments suffered by the deceased that existed at the time of admission?   Yes        No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of contributory illnesses","type":"text","label":"If yes, detail","options":[],"required":null,"pdf_field":""},{"help":"Provide discharge date","type":"date","label":"What was the date of discharge from the hospital?","options":[],"required":null,"pdf_field":""},{"help":"Describe condition at discharge","type":"text","label":"What was the condition of the deceased at the time discharge?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the deceased treated at the hospital at any other occasion as an out-patient or inpatient?     Yes     No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of other treatments at hospital","type":"text","label":"If yes, please provide details","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the deceased treated by any other medical practitioner/hospital during the past 3 years?      Yes     No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of other medical practitioner/hospital","type":"text","label":"If yes then provide the details: Name","options":[],"required":null,"pdf_field":""},{"help":"Address of other medical practitioner/hospital","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Contact number of other medical practitioner/hospital","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Name and designation of doctor","type":"text","label":"Name and Designation of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"Doctor's qualifications and code","type":"text","label":"Qualifications and code of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"Name of hospital","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Hospital registration number","type":"text","label":"Registration Number of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Hospital address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Hospital telephone number","type":"phone","label":"Telephone Number","options":[],"required":null,"pdf_field":""},{"help":"Mandatory hospital seal or stamp","type":"signature","label":"Seal / Stamp of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Date of certification","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of certifying authority","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital authorities"}],"deadlines":[],"applies_to":"","attachments":["patient admission sheet","investigations","history sheet","treatment records","admission notes","separate sheets for tests/investigations if required"],"declarations":["Certified that the above information is correct as per hospital records"],"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/canara-hsbc-life-insurance/124-treating-hospital-certificate-form-h"}