{"id":899,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/ASP%20Claim%20Form_0.pdf","sha256":"b566d8c8b744025dd893c7eca52c96d36ac3a94b4890b87052539016eae9d417","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used to request cashless hospitalisation under a Mediclaim insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Fill form in block letters","Use dd-mm-yyyy format for dates and hh:mm format for times","Attach all original bills and documents as per checklist","Page 1 only to be faxed or scanned for cashless request; original documents to be submitted after discharge","Hospital seal must contain hospital ID","Patient/Insured must sign after reading declaration on reverse","Use original documents only; photocopies must be certified","If injury is medico legal, attach MLC report and Police FIR","If injury due to substance abuse/alcohol, attach test reports","Pre-authorization number must be provided if obtained","If pre-authorization not obtained, give reason"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY","submit":{"to":"TPA / Insurance Company","how":"Fax / Scan page 1 only; submit original documents after discharge","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator","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":""}],"filled_by":""},{"title":"Details of the Hospital","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Include street, city, pin code","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"ROHINI ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact number of attending relative","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of the Insured / Patient","fields":[{"help":"","type":"text","label":"Insured card ID number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy number / Name of corporate","options":[],"required":true,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Include street, city, pin code","type":"text","label":"Current address of insured person","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation of insured person","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Details of Admission and Hospitalisation","fields":[{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of admission","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Expected no. of days in hospital","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of discharge","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Medical Details and Diagnosis","fields":[{"help":"","type":"text","label":"Provisional diagnosis","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Past history of any chronic illness","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter month and year","type":"text","label":"If Yes, since (month / year)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Any other Ailment, give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nature of illness/ disease with presenting complaints","options":[],"required":true,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Duration of the present ailment (days)","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of first consultation","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Room Type","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient's Diet","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"ICU Charges","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"OT Charges","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Professional fees Surgeon + Anesthetist Fees + consultation charges","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Medicines + Consumables + Cost of implants (if applicable)","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Expected cost of investigation + diagnostics","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Days in ICU","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","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":"","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":null,"pdf_field":""},{"help":"Attach test reports if yes","type":"yes-no","label":"Test conducted to establish this? (If yes attach reports)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Surgical, name of surgery","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable treatment","type":"choice","label":"Proposed line of treatment","options":["Medical Management","Surgical Management","Intensive Care","Investigation","AYUSH Treatment (Please Specify)"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a family physician?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the family physician","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Declaration by Patient / Insured","fields":[{"help":"Sign after reading declaration on reverse","type":"signature","label":"Patient / Insured Name & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"patient / insured"},{"title":"Declaration by Hospital","fields":[{"help":"Must contain hospital ID","type":"signature","label":"Hospital Seal","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Doctor's Signature","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Claim Form - Part A (To be filled by Insured)","fields":[{"help":"Enter policy number","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"Includes name, gender, age, DOB, address, phone, email, relationship to primary insured","type":"table","label":"Details of Primary Insured","options":[],"required":true,"pdf_field":""},{"help":"Includes current coverage, date of commencement, previous hospitalizations","type":"table","label":"Details of Insurance History","options":[],"required":true,"pdf_field":""},{"help":"Includes name, gender, DOB, occupation, address","type":"table","label":"Details of Insured Person Hospitalized","options":[],"required":true,"pdf_field":""},{"help":"Includes hospital name, address, dates and times of admission and discharge, reason for hospitalization","type":"table","label":"Details of Hospitalization","options":[],"required":true,"pdf_field":""},{"help":"Includes expenses claimed, treatment details, system of medicine","type":"table","label":"Details of Claim","options":[],"required":true,"pdf_field":""},{"help":"List bills submitted with number and amount","type":"table","label":"Details of Bills Enclosed","options":[],"required":true,"pdf_field":""},{"help":"Includes bank name, branch, account number, IFSC code, PAN","type":"table","label":"Details of Primary Insured's Bank Account","options":[],"required":true,"pdf_field":""},{"help":"Sign and date after reading declaration","type":"signature","label":"Declaration by the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Form - Part B (To be filled by Hospital)","fields":[{"help":"Includes hospital name, ID, type, address, phone, registration number, PAN, number of beds, facilities","type":"table","label":"Details of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Includes patient name, IP registration number, gender, age, DOB, admission and discharge dates and times, type of admission, maternity details, status at discharge","type":"table","label":"Details of Patient Admitted","options":[],"required":true,"pdf_field":""},{"help":"Includes ICD 10 codes and descriptions for primary diagnosis, additional diagnosis, co-morbidities, procedures","type":"table","label":"Details of Ailment Diagnosed (Primary)","options":[],"required":true,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":["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","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","Original Pre-authorization request","Copy of the Pre-authorization approval letter","Doctor's reference slip","Investigation reports (including CT / MRI / USG / HPE)","MLC report & Police FIR"],"required":true,"pdf_field":""},{"help":"Sign, seal, date and place after reading declaration","type":"signature","label":"Declaration by the Hospital","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":"Arogya Sanjeevani Policy - National","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","Original Pre-authorization request","Copy of the Pre-authorization approval letter","Doctor's reference slip","Investigation reports (including CT / MRI / USG / HPE)","MLC report & Police FIR","Copy of photo ID card of patient verified by hospital"],"declarations":["The information furnished in this form is true and correct to the best of knowledge and belief","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement","TPA / Insurance Company is authorized to seek necessary medical information from hospitals or medical practitioners","Patient agrees to allow 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; patient undertakes to settle bill if insurer/TPA is not liable","Non-medical expenses and amounts over authorized limits will be paid by the patient","Patient agrees to abide by policy terms and indemnify insurer/TPA in case of false information","Hospital confirms no additional amount will be collected from insured beyond agreed package rates except non-admissible amounts","Hospital agrees to provide clarifications for queries and takes responsibility for delays","Unauthorized recovery of additional amounts from insured may be recovered by TPA/Insurance Company from hospital"],"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/national-insurance/899-request-for-cashless-hospitalisation-for-mediclaim-insurance-policy"}