{"id":2352,"title":"HOSPITAL TREATMENT FORM","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/020816-hospital-treatment-form","sha256":"944dbf2d5f0abcc873c0c2d1aacb784fb7ef88684d80c4002871f5ea87765e09","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is for hospital authorities to fill in details of a patient's hospitalization and treatment to support an insurance claim.","notes":["If treatment is from more than one hospital, forms from all hospitals must be submitted.","If admission to ICU is for more than one spell, details of each admission must be given separately.","Patient photo ID must be affixed and attested by Principal Insured and Hospital Authorities.","Benefits under the policy are fixed as per daily benefit opted and are independent of actual expenses.","This form is to be filled by hospital authorities except the authorization section which is by the policyholder/claimant."],"title":"HOSPITAL TREATMENT FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Patient and Hospitalization Details","fields":[{"help":"","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"SEX","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"In.Patient No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Admission in Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission","type":"text","label":"Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Discharge from Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge","type":"text","label":"Time of Discharge","options":[],"required":null,"pdf_field":""},{"help":"If applicable","type":"date","label":"Date of Admission in ICU","options":[],"required":null,"pdf_field":""},{"help":"If applicable","type":"text","label":"Time of Admission in ICU","options":[],"required":null,"pdf_field":""},{"help":"If applicable","type":"date","label":"Date of Discharge from ICU","options":[],"required":null,"pdf_field":""},{"help":"If applicable","type":"text","label":"Time of Discharge from ICU","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Attending Doctor/Surgeon","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Regd. No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether present ailment/ disease is a complication of any pre-existing condition that the patient is suffering from?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"History of past illness/ ailment/ disease","options":[],"required":null,"pdf_field":""},{"help":"For past illness","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Duration of past illness","type":"text","label":"Duration of illness","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Past surgeries undergone","options":[],"required":null,"pdf_field":""},{"help":"If complication is yes","type":"text","label":"If ‘Yes’ please specify the disease/ailment (or) complication of any previous surgery and the onset of date of the disease","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the disease /ailment/disorder congenital in nature?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Brief description of the treatment given for present hospitalization","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"a) Nature of Surgery performed and Duration of surgery","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Specify the details of Surgery (laser, detailed procedure, any other modern technical incision)","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"In case of Accident Cases / RTA, whether a) Under the influence of Alcohol","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"hospital authorities"},{"title":"Hospital / Day Care Centre Details","fields":[{"help":"","type":"text","label":"Name of the Hospital & Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital Registration No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Registered under (1) Clinical Establishments (Registration & Regulation) Act, 2010I","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Registered under (2) Enactments specified under Schedule of Section 56(1) of Clinical Establishment Act,2010","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"number","label":"No. of beds:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registered under any other Act? If YES, pl. specify:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Is the Medical Centre under supervision of registered and qualified medical practitioner:","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Whether the hospital is having A fully equipped operation Theatre:","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"ICU UNIT:","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Qualified nurses Round the clock:","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Qualified doctors round the clock:","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Maintained daily records of patients:","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Are Daily Records accessible to LIC’s authorized personnel:","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"hospital authorities"},{"title":"Patient ID Card Affixation and Certification","fields":[{"help":"Affix and attest the patient's photo ID","type":"photo","label":"A Clear copy of the Health Card / Photo ID (eg. PAN card / Voter card / Passport / Driving License etc) of the patient needs to be affixed here and is to be attested by the Principal Insured (PI) and attested by the Hospital Authorities.","options":[],"required":true,"pdf_field":""},{"help":"Fill patient name and certify","type":"text","label":"Certificate: This is to certify that Sri/Smt/kum.______________________________ whose ID Card/Photo is pasted as above has undergone hospitalization treatment /surgical procedure as per details given above.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Doctor / Hospital Authorities with Hospital Seal","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital authorities and policyholder"},{"title":"Authorization by Policyholder/Claimant","fields":[{"help":"Fill hospital and TPA names","type":"text","label":"To, ____________________________________________________________ ____________________________________________________________ I hereby authorize the representatives of the TPA, M/S_______________________________ and Life Insurance Corporation of India free and unlimited access to seek medical information (Indoor case papers, reports, documents, including photocopies thereof pertaining to my / my family members’ admission/treatment etc.) from you.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"I also hereby authorize the hospital/attending doctor/medical practitioner from whom I/ my family member has sought medical attention/medical treatment concerning any disease/sickness, ailment or injury to part with the above information to the TPA/LIC of India or its representatives. Myself/my successors/assigns shall not raise any dispute or litigation on passing of such information to the TPA or LIC of India or its representatives.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Date & Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the policyholder/Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder/claimant"}],"deadlines":[],"applies_to":"","attachments":["A Clear copy of the Health Card / Photo ID (eg. PAN card / Voter card / Passport / Driving License etc) of the patient"],"declarations":["The hospital certifies that the treatment details given are true.","The policyholder authorizes TPA and LIC representatives to access medical information and releases them from disputes or litigation."],"dropped_labels":2},"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/lic/2352-hospital-treatment-form"}