{"id":709,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART - C (Revised)","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Cashless%20Preauthorization%20Request%20Form.pdf","sha256":"3968baa6941f803a264de7cb2583cd3e818b4896e686c500f38176b6dbc32e6c","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used to request cashless hospitalisation under a health insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Fill all details in block letters where specified.","Attach reports if tests are conducted for substance abuse or alcohol consumption.","Use original documents countersigned by insured/patient as per checklist.","Please send cashless requests to Preauth@Libertyinsurance.in.","For queries contact Liberty General Insurance Limited, Liberty Health 360, The Capitol, 3rd Floor, Near Ashoka Hotel, Vishal Nagar, New DP road, Pune 411027. Phone 020-67125757."],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART - C (Revised)","submit":{"to":"Preauth@Libertyinsurance.in","how":"e-mail","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator/ Insurer/ Hospital","fields":[{"help":"Fill in block letters","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":""},{"help":"","type":"text","label":"Name of Hospital :","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"To be filled by the Insured / Patient","fields":[{"help":"Fill in block letters","type":"text","label":"Name of the Patient :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender :","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact number :","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 / 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":"If other Mediclaim / Health Insurance is Yes","type":"text","label":"Company Name :","options":[],"required":null,"pdf_field":""},{"help":"If other Mediclaim / Health Insurance is Yes","type":"text","label":"Give Details :","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a family physician :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If family physician is Yes","type":"text","label":"Name of the Family Physician:","options":[],"required":null,"pdf_field":""},{"help":"If family physician is Yes","type":"phone","label":"Contact number, if any:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Current Address of Insured Patient:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation of Insured Patient:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact number of attending Relative :","options":[],"required":null,"pdf_field":""},{"help":"If ABHA ID is not available, visit https://abdm.gov.in/ for creation and inform once created","type":"text","label":"ABHA Id :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"To be filled by the Treating Doctor / Hospital","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 complaints","type":"text","label":"Nature of ILLNESS / Disease with presenting complaints :","options":[],"required":null,"pdf_field":""},{"help":"Duration in days/months/years","type":"text","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":"International Classification of Diseases code","type":"text","label":"ICD 10 Code :","options":[],"required":null,"pdf_field":""},{"help":"Select all applicable","type":"choice","label":"Proposed line of treatment :","options":["Medical Management","Surgical Management","Intensive care","Investigation","Non allopathic treatment"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If Investigation & / or Medical Management provide details","options":[],"required":null,"pdf_field":""},{"help":"Specify route (oral, IV, etc.)","type":"text","label":"Route of drug administration :","options":[],"required":null,"pdf_field":""},{"help":"If surgical management selected","type":"text","label":"If Surgical, name of surgery:","options":[],"required":null,"pdf_field":""},{"help":"Procedure coding system code","type":"text","label":"ICD 10 PCS Code :","options":[],"required":null,"pdf_field":""},{"help":"Specify other treatments if any","type":"text","label":"If other treatments provide details:","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of injury if applicable","type":"text","label":"How did injury occur :","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of injury :","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If reported to police","type":"text","label":"FIR No","options":[],"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":"Attach reports if Yes","type":"yes-no","label":"Test conducted to establish this :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Gravida, Para, Living children, Abortions","type":"text","label":"In case of Maternity : G P L A","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":"DD/MM/YYYY","type":"date","label":"Date of admission :","options":[],"required":null,"pdf_field":""},{"help":"HH:MM","type":"text","label":"Time of admission :","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Expected no. of days stay in hospital :","options":[],"required":null,"pdf_field":""},{"help":"Specify room type","type":"text","label":"Room Type :","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient’s Diet : Rs","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Expected cost for investigation + diagnostics : Rs","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"ICU Charges : Rs","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"OT Charges : Rs","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Professional fees Surgeon + Anesthetist Fees + consultation Charges : Rs","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Medicines + Consumables + Cost of Implants (If applicable please specify): Other hospital expenses if any : Rs","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"All inclusive package charges if any applicable : Rs","options":[],"required":null,"pdf_field":""},{"help":"List chronic illnesses and since when (month/year)","type":"table","label":"Mandatory: Past History of any chronic illness If yes, since (month / year)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Details of the patient admitted","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"","type":"text","label":"Name of the Patient :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"e-mail Id (optional) :","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date :","options":[],"required":null,"pdf_field":""},{"help":"HH:MM","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""}],"filled_by":"patient or representative"},{"title":"Declaration by the Treating Doctor / Hospital","fields":[{"help":"","type":"text","label":"Name of the treating doctor :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No. with State Code :","options":[],"required":null,"pdf_field":""},{"help":"Hospital official seal","type":"signature","label":"Hospital Seal (Must include Hospital ID)","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Doctor’s Signature :","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date :","options":[],"required":null,"pdf_field":""},{"help":"HH:MM","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor / hospital"}],"deadlines":["All valid original documents to be sent to TPA / Insurance Company within 7 days of the patient's discharge"],"applies_to":"health insurance cashless hospitalisation requests","attachments":["Reports if test conducted to establish substance abuse / alcohol consumption","All valid original documents duly countersigned by the insured / patient as per the checklist"],"declarations":["I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer / TPA after discharge and to sign the final bill and discharge summary before discharge.","Payment to hospital is governed by the terms and conditions of the policy; if insurer/TPA is not liable, I will settle the bill as per policy terms.","All non-medical expenses and expenses not relevant to current hospitalization and amounts over the authorized limit will be paid by me.","I declare to abide by the policy terms and if any facts disclosed are false or incorrect, I forfeit my claim and agree to indemnify the Insurer/TPA.","I understand TPA does not warrant hospital services or guarantee quality or standard of services provided by the hospital.","I warrant the truth of all particulars and agree that any false or untrue statement or concealment will forfeit my claim.","I agree to indemnify the hospital against expenses not reimbursed by the Insurer/TPA.","I authorize Insurance Company/TPA to contact me through mobile/email for any update on this claim.","Hospital agrees to allow authorized TPA/Insurance officials to verify documents and send all valid original documents within 7 days of discharge.","Hospital agrees to abide by terms in the MOU and not collect amounts in excess of agreed package rates except for non-admissible amounts.","Hospital agrees that unauthorized recovery of additional amounts from insured may be recovered by TPA/Insurance Company."],"dropped_labels":6},"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/liberty-general-insurance/709-request-for-cashless-hospitalisation-for-health-insurance-policy-part-c-revised"}