{"id":125,"title":"Hospital Treatment Form: (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/health-insurance-claims/hospital-certificate.pdf","sha256":"c412f8bf95a109f526feb4d06a0b3d5759336dc14d2315b339ecb7029d95defb","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is to be completed by hospital authorities to provide detailed information about the hospitalization of the patient (Life Assured) for insurance claim processing.","notes":["One form is to be filled up per hospital/nursing home","Attach all supporting documents as listed","Seal/Stamp of the hospital is mandatory"],"title":"Hospital Treatment Form: (Form–H)","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Hospital and Patient Details","fields":[{"help":"","type":"text","label":"Policy no(s)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Patient/ Life Assured","options":[],"required":null,"pdf_field":""},{"help":"Write age in years and any identifying marks","type":"text","label":"Age_____ years,  Any mark of identification?","options":[],"required":null,"pdf_field":""},{"help":"Date format DD/MM/YYYY; time with a.m./p.m.","type":"date","label":"Date and Time of admission","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Admission no.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the patient (Life Assured) referred by any doctor/ hospital Yes    No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide referring doctor/hospital name and address if referred","type":"text","label":"If yes, then provide with the name and address","options":[],"required":null,"pdf_field":""},{"help":"Contact number of referring doctor/hospital","type":"phone","label":"Contact no.","options":[],"required":null,"pdf_field":""},{"help":"Describe patient's complaints or condition on admission","type":"text","label":"What were the complaints/ condition of the patient (Life Assured) at the time of admission","options":[],"required":null,"pdf_field":""},{"help":"Describe illness nature and duration; attach admission notes","type":"text","label":"What was the exact nature and duration of the illness suffered by the patient (Life Assured)? (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":"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":"Doctor's name and qualification who recorded history","type":"text","label":"Name of the  doctor who recorded the history with qualification","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Did the patient (Life Assured) suffer from any past ailment as disclosed at the time of admission? Yes    No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of past ailment and duration if any","type":"text","label":"If yes, then provide details of the nature of the ailment and its duration","options":[],"required":null,"pdf_field":""},{"help":"Diagnosis as per hospital records","type":"text","label":"What was the diagnosis made at the hospital","options":[],"required":null,"pdf_field":""},{"help":"List tests/investigations; attach sheets if needed","type":"text","label":"What were the tests/ investigations undergone by the patient (Life Assured) at the hospital to confirm the diagnosis? (Please attach separate sheets if required)","options":[],"required":null,"pdf_field":""},{"help":"Date of diagnosis confirmation","type":"date","label":"When was the diagnosis confirmed at the hospital?","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital authorities"},{"title":"Treatment and Discharge Details","fields":[{"help":"Describe treatment provided during hospitalization","type":"text","label":"What was the treatment given to the patient (Life Assured) 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 patient (Life Assured) that existed at the time of admission? Yes    No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other contributory or chronic ailments","type":"text","label":"If yes, detail","options":[],"required":null,"pdf_field":""},{"help":"Date format DD/MM/YYYY","type":"date","label":"What was the date of discharge from the hospital?","options":[],"required":null,"pdf_field":""},{"help":"Patient's condition at discharge","type":"text","label":"What was the condition of the patient (Life Assured) at the time discharge?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the patient (Life Assured) treated at the hospital at any other occasion as an out-patient or inpatient? Yes    No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other treatments at this hospital","type":"text","label":"If yes, please provide details","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the patient (Life Assured) 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":""}],"filled_by":"hospital authorities"},{"title":"Certification by Doctor and Hospital Details","fields":[{"help":"Date of certification","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of certification","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of certifying doctor","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name and designation","type":"text","label":"Name and Designation of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"Doctor's qualifications and registration number","type":"text","label":"Qualifications and Registration number of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"Hospital name","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":"Hospital seal or stamp is mandatory","type":"attachment","label":"Seal / Stamp of the Hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"doctor and hospital"}],"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/125-hospital-treatment-form-formh"}