{"id":752,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART - C (Revised)","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/0/Pre-authorization+Form+%28Part+C%29+%E2%80%93+Saksham+Health+Insurance.pdf/0de0e3ab-b821-9b81-c115-58ae088203f7?t=1765020310078","sha256":"d1bf24c15252189bafe25fadd130fa0b5f007654e3e58470e78518587d783151","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for requesting cashless hospitalisation under a health insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Fill form in block letters.","Attach original documents as per checklist.","Use original bills only.","Patient/insured must sign declarations.","Hospital must seal and sign the form.","Time formats are HH:MM; date formats are DD MM YYYY."],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART - C (Revised)","submit":{"to":"TPA / Insurance Company","how":"sent within 7 days of patient’s discharge","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator/Insurer/Hospital","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":""},{"help":"","type":"text","label":"Name of Hospital:","options":[],"required":null,"pdf_field":""},{"help":"Full postal address of the hospital","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Hospital's Rohini ID if applicable","type":"text","label":"Rohini ID","options":[],"required":null,"pdf_field":""},{"help":"Hospital's email address","type":"email","label":"e-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details to be filled by Insured/Patient","fields":[{"help":"First, Middle, Last names in block letters","type":"text","label":"Name of the Patient:","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Gender:","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Enter age in years and/or months","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code for landline; mobile number mandatory","type":"phone","label":"Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Contact Number of attending Relative:","options":[],"required":null,"pdf_field":""},{"help":"As per insurance card","type":"text","label":"Insured Card ID number:","options":[],"required":null,"pdf_field":""},{"help":"Policy number or corporate name","type":"text","label":"Policy Number/Name of Corporate","options":[],"required":null,"pdf_field":""},{"help":"If applicable","type":"text","label":"Employee ID:","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"yes-no","label":"Currently do you have any other mediclaim /health insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes to above, name of other insurer","type":"text","label":"Company Name:","options":[],"required":false,"pdf_field":""},{"help":"Details of other insurance","type":"text","label":"Give Details:","options":[],"required":false,"pdf_field":""},{"help":"Select one","type":"yes-no","label":"Do you have a family Physician:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes","type":"text","label":"Name of the Family Physician:","options":[],"required":false,"pdf_field":""},{"help":"Family physician contact number","type":"phone","label":"Contact number, if any:","options":[],"required":false,"pdf_field":""},{"help":"Full current address","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":""}],"filled_by":"insured/patient"},{"title":"Details to be filled by 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 complaint:","options":[],"required":null,"pdf_field":""},{"help":"Important clinical findings","type":"text","label":"Relevant Critical Findings:","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Duration of the present ailment","options":[],"required":null,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Date of First consultation:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Past history of present ailment, if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Provisional diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"If known","type":"text","label":"ICD 10 code:","options":[],"required":false,"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":"Details of investigations or medical management","type":"text","label":"If investigation and/or Medical Management provide details:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Route of Drug Administration:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If surgical, name of surgery:","options":[],"required":false,"pdf_field":""},{"help":"If known","type":"text","label":"ICD 10 PCS code:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If other treatment, provide details:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"How did injury occur:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"In case of accident:","options":[],"required":false,"pdf_field":""},{"help":"Road Traffic Accident","type":"yes-no","label":"Is it RTA:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Date of Injury:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Report to Police:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Police FIR number 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 report if yes","type":"yes-no","label":"Test conducted to establish this (if yes, attach report):","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"G, P, L, A details","type":"text","label":"In case of Maternity:","options":[],"required":false,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Expected date of Delivery:","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Details of Patient Admitted","fields":[{"help":"DD MM YYYY format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"HH : MM format","type":"text","label":"Time of admission","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Is this an emergency/planned hospitalization event","options":["Emergency","Planned"],"required":null,"pdf_field":""},{"help":"Fill for each illness: Diabetes, Heart disease, Hypertension, Hyperlipidemias, Osteoarthritis, Asthma/COPD/Bronchitis, Cancer, Alcohol/Drug abuse, Any HIV/or STD Related ailment, Any other ailment (give details)","type":"table","label":"Mandatory Past History of any chronic illness If yes (Since month/year)","options":[],"required":null,"pdf_field":""},{"help":"Number of days expected","type":"number","label":"Expected number of Days/stay in hospital","options":[],"required":null,"pdf_field":""},{"help":"Number of ICU days expected","type":"number","label":"Days in ICU","options":[],"required":null,"pdf_field":""},{"help":"Type of room requested","type":"text","label":"Room Type","options":[],"required":null,"pdf_field":""},{"help":"Expected per day charges","type":"amount","label":"Per day room rent + nursing and service charges+ patients diet","options":[],"required":null,"pdf_field":""},{"help":"Expected investigation costs","type":"amount","label":"Expected cost of investigation + diagnostic","options":[],"required":null,"pdf_field":""},{"help":"Expected ICU charges","type":"amount","label":"ICU Charges","options":[],"required":null,"pdf_field":""},{"help":"Expected operation theatre charges","type":"amount","label":"OT Charges","options":[],"required":null,"pdf_field":""},{"help":"Expected professional fees","type":"amount","label":"Professional fees Surgeon + Anesthetist Fees + consultation Charges:","options":[],"required":null,"pdf_field":""},{"help":"Expected cost of medicines and consumables","type":"amount","label":"Medicines + Consumables + Cost of Implants (if applicable please specify)","options":[],"required":null,"pdf_field":""},{"help":"Any other expected hospital expenses","type":"amount","label":"Other hospital expenses if any","options":[],"required":false,"pdf_field":""},{"help":"If package charges apply","type":"amount","label":"All-inclusive package charges if any applicable","options":[],"required":false,"pdf_field":""},{"help":"Total expected cost","type":"amount","label":"Sum Total expected cost of hospitalization","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Declaration by Treating Doctor and Patient/Representative","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 number with State code","options":[],"required":null,"pdf_field":""},{"help":"Signature of patient or insured","type":"signature","label":"Patient/Insured Name and Sign","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor and patient/representative"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"","type":"text","label":"Patient’s / Insured’s Name:","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":"Signature of patient or insured","type":"signature","label":"Patient’s / Insured’s Signature:","options":[],"required":true,"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/representative"},{"title":"Hospital Declaration","fields":[{"help":"Official hospital seal","type":"signature","label":"Hospital Seal","options":[],"required":null,"pdf_field":""},{"help":"Signature of treating doctor","type":"signature","label":"Doctor’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":"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 policy Part - C cashless hospitalisation requests","attachments":["Test report to establish injury due to substance abuse/alcohol consumption (if applicable)","All valid original documents duly countersigned by the insured/patient as per the checklist"],"declarations":["Patient agrees to allow hospital to submit all original hospitalization documents to Insurer/TPA after discharge.","Patient agrees to sign final bill and discharge summary before discharge.","Payment to hospital is governed by policy terms; patient will settle bill if insurer/TPA is not liable.","Patient will pay all non-medical and non-covered expenses and amounts above authorized limits.","Patient declares all information is true and agrees to indemnify insurer/TPA if false.","TPA does not guarantee hospital service quality.","Patient agrees to indemnify hospital for expenses not reimbursed by insurer/TPA.","Patient authorizes insurer/TPA to contact via mobile/email for claim updates.","Hospital agrees to allow authorized TPA/Insurance officials to verify hospitalization documents.","Hospital will send all valid original documents countersigned by insured/patient to TPA/Insurance within 7 days of discharge.","Hospital agrees TPA/Insurance is not liable for payment if discrepancies exist between form and documents.","Hospital confirms patient declaration was signed in their presence.","Hospital agrees to provide clarifications and takes responsibility for delays.","Hospital will abide by terms of MOU with insurer/TPA.","Hospital confirms no extra amount will be collected from insured beyond agreed package rates except non-admissible costs.","Hospital confirms no recoveries from deposit except for non-admissible costs.","Hospital acknowledges TPA/Insurance may recover unauthorized extra amounts from them or take action."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Magma General Insurance Limited (Claims Hub), Srinilaya Cyber Spazio Suite 101, 102, Ground Floor, Road No. 2, Banjara Hills, Hyderabad, Telangana – 500034","label":"Claims Hub Address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.magmainsurance.com/learn-about-claims","quote":"fe takes an unexpected turn. When that moment comes, a clear and dependable claims process makes all the difference. At Magma General Insurance, our aim is to make the process simple to understand, transparent to follow, and supportive at every step. This page explains how claims work across Health, Motor and Non‑Motor policies.\nClaim is easy at Magma General Insurance.\nRegister Claim\nHealth","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"customercare@magmainsurance.com","label":"Customer Care Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.magmainsurance.com/web/magmainsurance/claims","quote":"ma HDI General Insurance Company Limited) | All Rights Reserved\n| IRDAI Reg. No. 149 |\nwww.magmainsurance.com\n| E-mail:\ncustomercare@magmainsurance.com\n| Registered & Corporate Office: Equinox Business Park, Tower 3, Ambedkar Nagar, 2\nnd\nFloor, Unit Number 1B & 2B, LBS M","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 266 3202","label":"Claims Intimation Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.magmainsurance.com/web/magmainsurance/claims","quote":"surance Claims - Motor & Health Insurance Claim Process - Magma Insurance - Magma\nSkip to Content\nOne-Line-Hearder-Test\n1800 266 3202\nNavigation\nCustomer Service\nSenior Citizen Services\nRoad side Assistance\nAnnual Health Check-up\nPolicy Servicing assist","fetched_at":"2026-10-20"}],"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/magma-general-insurance/752-request-for-cashless-hospitalisation-for-health-insurance-policy-part-c-revised"}