{"id":2296,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/NSIP%20Claim%20Form.pdf","sha256":"cdb26882e136215ade90adb5fa9e9bfc66e293d677310f1bedc95effe6d80339","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used to request cashless hospitalisation under a Mediclaim insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Fill the form in block letters","Use original bills only","Use dd/mm/yyyy format for dates and hh:mm format for times","Attach all required supporting documents as per checklist","Patient must sign the declaration in presence of hospital representative","Hospital must seal and sign the form","Submit only page 1 for cashless request via fax/scan","Part A is filled by insured, Part B by hospital","Keep a copy of all submitted documents for your records"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY","submit":{"to":"TPA / Insurance Company as per policy","how":"Fax / Scan / Upload as per instructions","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator","fields":[{"help":"","type":"text","label":"Name of TPA / Insurance Company","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll free phone number","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll free Fax","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of the Patient Admitted","fields":[{"help":"Fill in block letters","type":"text","label":"Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"Tick M for Male, F for Female or TG for Transgender","type":"choice","label":"Gender","options":["M","F","TG"],"required":true,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Employee ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Insured card ID number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy number / Name of corporate","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Current address of insured person","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation of insured person","options":[],"required":false,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of admission","options":[],"required":true,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Expected no. of days in hospital","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days in ICU","type":"number","label":"Days in ICU","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Provisional diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Expected cost of investigation + diagnostics (INR)","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"ICU Charges (INR)","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"OT Charges (INR)","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Professional fees Surgeon + Anesthetist Fees + consultation charges (INR)","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Medicines + Consumables + Cost of implants (if applicable, please specify) (INR)","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"All inclusive package charges, if any applicable (INR)","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Other hospital expenses, if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a family physician?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the family physician","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Contact number of attending relative","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"To be filled by the Treating Doctor / Hospital","fields":[{"help":"Full name","type":"text","label":"Name of the treating doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact number","options":[],"required":false,"pdf_field":""},{"help":"Doctor's registration number with state code","type":"text","label":"Registration No. with state code","options":[],"required":true,"pdf_field":""},{"help":"Doctor's educational qualifications","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Describe illness and complaints","type":"text","label":"Nature of illness/ disease with presenting complaints","options":[],"required":true,"pdf_field":""},{"help":"Number of days","type":"number","label":"Duration of the present ailment (days)","options":[],"required":false,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of first consultation","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Past history of management, provide details","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable treatment(s)","type":"choice","label":"Proposed line of treatment","options":["Medical Management","Surgical Management","Intensive Care","Investigation","AYUSH Treatment (Please Specify)"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If surgical, name of surgery","options":[],"required":false,"pdf_field":""},{"help":"International Classification of Diseases code","type":"text","label":"ICD 10 Code (if any)","options":[],"required":false,"pdf_field":""},{"help":"Procedure coding system code","type":"text","label":"ICD 10 PCS Code","options":[],"required":false,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of injury","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach FIR copy if applicable","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Injury / Disease caused due to substance abuse / alcohol consumption","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach test reports if yes","type":"yes-no","label":"Test conducted to establish this? (If yes attach reports)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"How did the injury occur?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Mandatory: Past history of any chronic illness","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Month and year","type":"text","label":"If Yes, since (month / year)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Any other Ailment, give details","options":[],"required":false,"pdf_field":""},{"help":"Type of room occupied","type":"text","label":"Room Type","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient's Diet","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"","type":"text","label":"Patient / Insured's Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Patient / Insured's Signature","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":""},{"help":"","type":"yes-no","label":"I/We authorize Insurance Company/TPA to contact me/us through mobile/email for any update on this claim","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"patient / insured"},{"title":"Declaration by the Hospital","fields":[{"help":"Hospital official seal","type":"signature","label":"Hospital Seal (must contain hospital ID)","options":[],"required":true,"pdf_field":""},{"help":"Signature of treating doctor","type":"signature","label":"Doctor's Signature","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":"hospital"},{"title":"Claim Form - Part A (To be filled by the insured)","fields":[{"help":"","type":"text","label":"Policy no","options":[],"required":true,"pdf_field":""},{"help":"Full name of primary insured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Gender","options":["M","F","TG"],"required":true,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Basic Sum insured","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Currently covered by any other Mediclaim/ Health Insurance","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you been hospitalized in the last four years since inception of the contract?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first insurance without break","options":[],"required":false,"pdf_field":""},{"help":"Include name of hospital, dates and times of admission and discharge, reason for hospitalization","type":"table","label":"Details of hospitalization","options":[],"required":true,"pdf_field":""},{"help":"List number and type of bills enclosed","type":"table","label":"Details of bills enclosed","options":[],"required":true,"pdf_field":""},{"help":"Include PAN, account number, bank name, branch, IFSC code, cheque/DD payable details","type":"text","label":"Details of primary insured's bank account","options":[],"required":true,"pdf_field":""},{"help":"Sign and date after reading declaration","type":"signature","label":"Declaration by the insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Form - Part B (To be filled by the hospital)","fields":[{"help":"Full name of hospital","type":"text","label":"Name of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"As allocated by the TPA","type":"text","label":"Hospital ID","options":[],"required":true,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Type of Hospital","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"Hospital registration number","type":"text","label":"Registration No. with state code","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address of the hospital","options":[],"required":true,"pdf_field":""},{"help":"Name, IP registration number, date of admission, discharge, times, type of admission","type":"text","label":"Details of patient admitted","options":[],"required":true,"pdf_field":""},{"help":"ICD 10 codes and descriptions for diagnosis, procedures, co-morbidities","type":"text","label":"Details of ailment diagnosed (primary)","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Pre authorization obtained","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"As allotted by TPA","type":"text","label":"Pre-authorization number","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Hospitalization due to injury","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick applicable cause","type":"choice","label":"If yes, give cause","options":["Self inflicted","Road Traffic Accident","Substance abuse / alcohol consumption"],"required":false,"pdf_field":""},{"help":"Attach reports if yes","type":"yes-no","label":"If injury due to Substance abuse / alcohol consumption, Test Conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"If Medico Legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach FIR copy if applicable","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If not reported to police, give reason","options":[],"required":false,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim documents submitted - checklist","options":["Claim Form duly signed","Investigation reports","Original Pre-authorization request","CT/ MRI/ USG/ HPE/ Investigation reports","Copy of the Pre-authorization approval letter","Doctor's reference slip","Hospital main bill","Original death summary from hospital, where applicable","Hospital break-up bill","Any other (please specify)"],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"Hospital PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter number of beds","type":"number","label":"Number of inpatient beds","options":[],"required":false,"pdf_field":""},{"help":"Tick available facilities","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Others (please specify)"],"required":false,"pdf_field":""},{"help":"Tick applicable status","type":"choice","label":"Status at time of discharge","options":["Discharged to home","Discharged to another hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Enter total amount claimed in INR","type":"amount","label":"Total claimed amount","options":[],"required":true,"pdf_field":""},{"help":"Signature and seal of hospital authority with date and place","type":"signature","label":"Declaration by the hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["Hospital to send all valid original documents duly countersigned by the insured / patient to TPA / Insurance Company within 7 days of the patient's discharge"],"applies_to":"Mediclaim insurance policies under the National Surrogacy Insurance Policy","attachments":["Detailed Discharge Summary and all Bills from the hospital","Cash Memos from the Hospitals / Chemists supported by proper prescription","Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests","Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt","Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured","Original Pre-authorization request form","Copy of the Pre-authorization approval letter","Doctor's reference slip","Original death summary from hospital, where applicable","MLC report & Police FIR (if applicable)"],"declarations":["The information furnished in this form is true and correct to the best of the signer's knowledge","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement","No benefits are admissible under any other Medical Scheme or Insurance for the same treatment","The insured agrees to indemnify the hospital against expenses not reimbursed by the Insurer / TPA","The hospital declares the information furnished is true and correct and false statements will forfeit claim rights","The insured authorizes the Insurance Company/TPA to contact them for claim updates","The hospital agrees to submit all original documents pertaining to hospitalization to the Insurer/TPA after discharge","Payment to hospital is governed by the terms and conditions of the policy","Non-medical expenses and amounts over authorized limits will be paid by the insured","TPA / Insurance Company does not guarantee the quality or standard of hospital services","Unauthorized recovery of amounts in excess of agreed package rates may lead to recovery actions against the hospital"],"dropped_labels":7},"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/national-insurance/2296-request-for-cashless-hospitalisation-for-mediclaim-insurance-policy"}