{"id":2300,"title":"UHIP Claim Form","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/UHIP%20Claim%20Form.pdf","sha256":"5eb6f9f65f1919f716bd508364cc67255da2db510bf5a17f0bf2b0c512e4582b","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used to request cashless hospitalisation and to claim reimbursement under the Universal Health Insurance Policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Fill all fields in block letters","Use dd-mm-yyyy format for dates and hh:mm for times","Attach all original bills and documents as per checklist","Submit page 1 only for cashless hospitalisation request by fax or scan","Submit original documents after discharge within 7 days","Use standard ICD 10 and ICD 10 PCS codes where applicable","Hospital declaration and signatures are mandatory","Policy number and insured details must be accurate","Ensure all declarations are read and signed","For non-network hospitals, additional details must be filled"],"title":"UHIP Claim Form","submit":{"to":"TPA / Insurance Company as per details on the form","how":"Fax / Scan page 1 only for cashless request; submit original documents after discharge","address":"Premises No. 18-0374, Plot no. CBD-81, New Town, Kolkata - 700156"},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator","fields":[{"help":"","type":"text","label":"a) Name of TPA / Insurance Company:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"b) Toll free phone number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"c) 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":"a) Name of the patient:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"b) Gender :","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"c) Age:  years","options":[],"required":true,"pdf_field":""},{"help":"Enter age in months if applicable","type":"number","label":"months","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"d) Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"e) Contact number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"f) Provisional diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"i) Employee ID:","options":[],"required":false,"pdf_field":""},{"help":"If yes to above, provide company name","type":"text","label":"Company Name:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"k) Do you have a family physician?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"l) Name of the family physician:","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"m) Contact number, if any:","options":[],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"n) Current address of insured person","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"o) Occupation of insured person:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"a) Date of admission:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"b) Time:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"c) Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"f) Provisional diagnosis:","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"m) In case of maternity: Expected date of Delivery:","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":"a) Name of the treating doctor:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"b) Contact number:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"c) Nature of illness/ disease with presenting complaints","options":[],"required":true,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"e) Duration of the present ailment:","options":[],"required":false,"pdf_field":""},{"help":"Use standard ICD 10 format","type":"text","label":"i) ICD 10 Code if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"k) How did the injury occur?","options":[],"required":false,"pdf_field":""},{"help":"Fill subfields below","type":"section","label":"l) In case of accident:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"i. Is it RTA?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"ii. Date of injury:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"iii. Reported to Police:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"iv. FIR No.:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"v. Injury / Disease caused due to substance abuse / alcohol consumption:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Doctor's registration number with state code","type":"text","label":"c) Registration No. with state code:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's educational qualifications","type":"text","label":"b) Qualification:","options":[],"required":true,"pdf_field":""},{"help":"If yes, specify since when (month/year)","type":"yes-no","label":"d) Mandatory : Past history of any chronic illness","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Any other Ailment, give details:","options":[],"required":false,"pdf_field":""},{"help":"Specify room type occupied","type":"text","label":"g) Room Type:","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"h) 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":"a) Patient/ Insured's Name:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"b) Contact number:","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"c) E-mail ID:","options":[],"required":false,"pdf_field":""},{"help":"Sign after reading declaration","type":"signature","label":"d) Patient/ Insured's Signature:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"e) Date:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"f) Time:","options":[],"required":false,"pdf_field":""}],"filled_by":"patient or representative"},{"title":"Claim Form - Part A (To be filled by the Insured)","fields":[{"help":"Enter policy number","type":"text","label":"a) Policy no:","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"c) Age:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"d) Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"e) Gender:","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"g) Occupation:","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please specify)"],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"h) Address (if different from above):","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"r) Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN:","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account Number:","options":[],"required":true,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name:","options":[],"required":true,"pdf_field":""},{"help":"Name of bank branch","type":"text","label":"Bank Branch:","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC Code:","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign after reading declaration","type":"signature","label":"Signature of 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":"a) Name of the Hospital:","options":[],"required":true,"pdf_field":""},{"help":"As allocated by TPA","type":"text","label":"b) Hospital ID:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"c) Type of Hospital:","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"Full name","type":"text","label":"d) Name of treating doctor:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualifications","type":"text","label":"e) Qualification:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number with state code","type":"text","label":"f) Registration No. with state code:","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"g) Phone No.:","options":[],"required":false,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"i) Time:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"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":"Universal Health 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","Copy of the claim intimation, if any","MLC Report & Police FIR attached (if applicable)","Original Pre-authorization request form (for Part B)","Copy of photo ID card of patient verified by hospital"],"declarations":["I agree to allow the hospital 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; if insurer/TPA is not liable, I undertake to settle the bill","All non-medical expenses and expenses not relevant to current hospitalization and amounts over authorized limits will be paid by me","I declare to abide by the terms and conditions of the policy and forfeit claim if any information is false or incorrect","I understand TPA does not guarantee hospital services or their quality","Hospital confirms no additional amount will be collected from insured beyond agreed package rates except for non-admissible costs","Hospital confirms no recoveries will be made from deposit amount except for non-admissible costs","In case of unauthorized recovery from insured, TPA/Insurance Company reserves right to recover from hospital","Information furnished in this claim form is true and correct to the best of my knowledge and belief","I consent and authorize TPA/insurance company to seek necessary medical information from hospitals or medical practitioners","I have included all bills/receipts for this claim and will not make supplementary claims except pre/post-hospitalization claims"],"dropped_labels":72},"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/2300-uhip-claim-form"}