{"id":360,"title":"Pre-Authorisation Form","purpose":"claim","insurer":{"slug":"care-health-insurance","name":"Care Health Insurance Ltd"},"source_pdf":"https://cms.careinsurance.com/cms/public/uploads/download_center/pre-authorization-form.pdf","sha256":"4733f6ebe76a591ac2b40a57e7cc2057f33114e396ef0e7d0f06cd25d45dda0a","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is for requesting cashless hospitalisation under a medical insurance policy. It is filled by the insured/patient and the treating doctor/hospital.","notes":["To be filled in CAPITAL LETTERS only","If insufficient space, provide details on a separate sheet","Do not fax or scan the patient declaration page","Use original documents only","Hospital declaration must be signed in presence of patient","Attach reports for tests conducted to establish accident if applicable"],"title":"Pre-Authorisation Form","submit":{"to":"","how":"Fax/Scan Page 1 & 2 only","address":""},"purpose":"claim","sections":[{"title":"Patient and Insured Details","fields":[{"help":"Enter full name in CAPITAL LETTERS","type":"text","label":"Name of the Patient :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender  :","options":["M","F","Other"],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age :","options":[],"required":null,"pdf_field":""},{"help":"Format DD/MM/YY","type":"date","label":"Date of Birth :","options":[],"required":null,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Contact Number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number of Attending Relative  :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured Card ID Number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee ID :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number/Name of Corporate :","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Currently do you have any other Mediclaim/Health Insurance :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a family physician :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide details of family physician","type":"text","label":"Give Details :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number, if any :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Company Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation of Insured Person :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the family physician :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Current Address of the Insured Patient :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/patient"},{"title":"Third Party Administrator (TPA) Details","fields":[{"help":"","type":"text","label":"Name of TPA/Insurance Company :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll Free Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Toll Free FAX :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Rohini ID :","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID :","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Treating Doctor/Hospital Details","fields":[{"help":"","type":"text","label":"Name of the treating doctor  :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number :","options":[],"required":null,"pdf_field":""},{"help":"Describe illness and symptoms","type":"text","label":"Nature of Illness/Disease with presenting complaints :","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Duration of the present ailment :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Provisional diagnosis :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Past history of present ailment if any :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relevant clinical findings:","options":[],"required":null,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of first consultation :","options":[],"required":null,"pdf_field":""},{"help":"If known","type":"text","label":"ICD 10 Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Investigation &/or Medical Management provide details :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Proposed line of treatment :","options":["Medical Management","Surgical Management","Intensive care","Investigation"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Route of drug administration :","options":[],"required":null,"pdf_field":""},{"help":"G, P, L, A values","type":"text","label":"In case of Maternity :","options":[],"required":null,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Delivery :","options":[],"required":null,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Admission :","options":[],"required":null,"pdf_field":""},{"help":"Format HH:MM","type":"text","label":"Time of Admission :","options":[],"required":null,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of injury :","options":[],"required":null,"pdf_field":""},{"help":"Attach reports if Yes","type":"yes-no","label":"Test conducted to establish this :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"FIR No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Is this an emergency/a planned hospitalization event?:","options":["Emergency","Planned"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Injury/Disease caused due to substance abuse/alcohol consumption :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"How did injury occur :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Surgical, name of surgery :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"ICD 10 PCS Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If other treatments provide details :","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Past History of Chronic Illness","fields":[{"help":"Month/Year since diagnosed","type":"text","label":"Hypertension (MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Month/Year since diagnosed","type":"text","label":"Hyperlipidemias (MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Month/Year since diagnosed","type":"text","label":"Diabetes (MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Month/Year since diagnosed","type":"text","label":"Heart Disease (MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Month/Year since diagnosed","type":"text","label":"Osteoarthritis (MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Month/Year since diagnosed","type":"text","label":"Asthma/COPD/Bronchitis (MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Month/Year since diagnosed","type":"text","label":"Alcohol or drug abuse (MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Month/Year since diagnosed","type":"text","label":"Cancer (MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other Ailment give details:","options":[],"required":null,"pdf_field":""},{"help":"Month/Year since diagnosed","type":"text","label":"Any HIV or STD / Related ailments (MM/YY)","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Expected Hospitalization Cost Details","fields":[{"help":"In Rs.","type":"amount","label":"Professional Fees Surgeon + Anesthetist Fees + Consultation Charges :","options":[],"required":null,"pdf_field":""},{"help":"In Rs.","type":"amount","label":"Medicines + Consumables + Cost of Implants (if applicable please specify). :","options":[],"required":null,"pdf_field":""},{"help":"In Rs.","type":"amount","label":"Other hospital Expenses: if any :","options":[],"required":null,"pdf_field":""},{"help":"In Rs.","type":"amount","label":"Expected cost for Investigation + Diagnostics :","options":[],"required":null,"pdf_field":""},{"help":"In Rs.","type":"amount","label":"All inclusive package charges if any applicable :","options":[],"required":null,"pdf_field":""},{"help":"In Rs.","type":"amount","label":"Sum Total expected cost of hospitalization :","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Expected no. of days stay in hospital :","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Days in ICU :","options":[],"required":null,"pdf_field":""},{"help":"Specify room type","type":"text","label":"Room Type :","options":[],"required":null,"pdf_field":""},{"help":"In Rs.","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient's Diet :","options":[],"required":null,"pdf_field":""},{"help":"In Rs.","type":"amount","label":"ICU Charges :","options":[],"required":null,"pdf_field":""},{"help":"In Rs.","type":"amount","label":"OT Charges :","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Hospital Declaration","fields":[{"help":"","type":"text","label":"Name of the treating doctor :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No. with State Code :","options":[],"required":null,"pdf_field":""},{"help":"Must include Hospital ID","type":"signature","label":"Hospital Seal","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Doctor's Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Patient/Insured Declaration","fields":[{"help":"","type":"text","label":"Patient's/Insured's Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Patient's/Insured's Signature :","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date :","options":[],"required":null,"pdf_field":""},{"help":"Time of signing","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""}],"filled_by":"patient/insured or representative"}],"deadlines":["All valid original documents will be sent to TPA/Insurance Company within 7 days of the patient's discharge"],"applies_to":"Request for Cashless Hospitalisation for Medical Insurance Policy","attachments":["All valid original documents duly countersigned by the insured/patient as per the checklist","Reports for tests conducted to establish accident if applicable"],"declarations":["I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TPA after discharge","I agree to sign on the Final Bill & Discharge Summary before discharge","I agree to indemnify the hospital against all expenses not reimbursed by the Insurer/TPA","I agree to settle hospital bills if insurer/TPA is not liable","I understand TPA/Insurer does not guarantee hospital service quality","I declare to abide by the policy terms and forfeit claim if false information is given","Hospital agrees to provide clarifications and abide by terms and conditions","No additional amount will be collected from insured beyond agreed package rates except non-admissible costs","I authorize Insurance Company/TPA to contact me for claim updates"],"dropped_labels":1},"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/care-health-insurance/360-pre-authorisation-form"}