{"id":901,"title":"National Home Care Treatment Add-on Claim Form","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Home%20Care%20Daily%20Monitoring%20cum%20Claim%20Form.pdf","sha256":"67977835ca7b36d97a36c864cc6686da2711695e6bce9eedc2d8c531a4fa65bc","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for submitting claims related to home care treatment under the National Home Care Treatment Add-on policy. It is filled by the insured person and the treating physician.","notes":["Submit all original or certified copies of documents related to the Home Care Treatment claim.","Fill the form in block letters.","The issue of this form is not to be taken as admission of liability.","Office use only sections are excluded from this form."],"title":"National Home Care Treatment Add-on Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Home Care Daily Monitoring","fields":[{"help":"Enter the day number of home care treatment","type":"number","label":"Day","options":[],"required":null,"pdf_field":""},{"help":"Enter the time of measurement","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Describe patient's appetite","type":"text","label":"Appetite","options":[],"required":null,"pdf_field":""},{"help":"Record body temperature in Fahrenheit or Celsius","type":"number","label":"Body Temperature (Farenhiet/Celsius)","options":[],"required":null,"pdf_field":""},{"help":"Record heart rate as measured by pulse oximeter","type":"number","label":"Heart Rate (from pulse oximeter)","options":[],"required":null,"pdf_field":""},{"help":"Record blood pressure in mm of Hg","type":"text","label":"Blood Pressure (mm of Hg)","options":[],"required":null,"pdf_field":""},{"help":"Record pulse rate","type":"number","label":"Pulse","options":[],"required":null,"pdf_field":""},{"help":"Record random blood glucose level in mg/dl","type":"number","label":"Random Blood Glucose (mg/dl)","options":[],"required":null,"pdf_field":""},{"help":"Record oxygen saturation percentage on room air","type":"number","label":"SpO2 % (from pulse oximeter) on Room Air","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of home care treatment","type":"date","label":"HOME CARE TREATMENT PERIOD DD/MM/YYYY to DD/MM/YYYY","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the patient","type":"text","label":"NAME OF PATIENT","options":[],"required":true,"pdf_field":""},{"help":"Signature of the patient or insured","type":"signature","label":"SIGNATURE","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the treating physician","type":"text","label":"NAME OF TREATING PHYSICIAN","options":[],"required":true,"pdf_field":""},{"help":"Physician's signature with seal/stamp and registration number","type":"signature","label":"SIGNATURE WITH SEAL/STAMP & REGISTRATION NUMBER","options":[],"required":true,"pdf_field":""}],"filled_by":"insured and treating physician"},{"title":"Additional Daily Monitoring Details","fields":[{"help":"Enter the day number of home care treatment","type":"number","label":"Day","options":[],"required":null,"pdf_field":""},{"help":"Record respiratory rate per minute","type":"number","label":"Respiratory Rate (per minute)","options":[],"required":null,"pdf_field":""},{"help":"Note presence or absence of diarrhea, nausea or vomiting","type":"text","label":"Diarrhea/Nausea or vomiting","options":[],"required":null,"pdf_field":""},{"help":"Describe any skin changes or rash","type":"text","label":"Skin changes or rash","options":[],"required":null,"pdf_field":""},{"help":"Record fluid intake and urine output if available","type":"text","label":"Fluid intake/Urine Output if measured","options":[],"required":null,"pdf_field":""},{"help":"Describe any other relevant signs or symptoms","type":"text","label":"Any other Sign/Symptom which may be related to the Home care treatment claimed for","options":[],"required":null,"pdf_field":""}],"filled_by":"insured and treating physician"},{"title":"Details of Claim and Bank Account","fields":[{"help":"Specify the purpose of the bills enclosed","type":"text","label":"DETAILS OF BILLS ENCLOSED - Bill Towards","options":[],"required":null,"pdf_field":""},{"help":"Enter the number of bills enclosed","type":"number","label":"No. of bills","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number for claim payment","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Enter name of the bank","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter details for cheque or demand draft if applicable","type":"text","label":"Cheque/ DD Payable details","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of the bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Provide details of the claim","type":"text","label":"DETAILS OF CLAIM - a) Details of Claim","options":[],"required":null,"pdf_field":""},{"help":"Tick all documents submitted with the claim","type":"checkbox","label":"Claim Documents Submitted- Check List","options":["Investigation Reports","Doctor's Prescription","Others","Diagnostic Tests","Medicines: Pharmacy Bill","Others Expenses","Medical Practitioner's Fees","Copy of the claim intimation, if any","Doctor's request for investigation","Claim Form Duly signed","Diagnosis"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Enter the date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter the place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of the insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Home Care Treatment claims under the National Home Care Treatment Add-on","attachments":["All original documents and/or certified copies related to the Home Care Treatment claim","Investigation Reports","Doctor's Prescription","Others","Diagnostic Tests","Medicines: Pharmacy Bill","Others Expenses","Medical Practitioner's Fees","Copy of the claim intimation, if any","Doctor's request for investigation","Claim Form Duly signed","Diagnosis"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements or concealment of material facts will forfeit the right to claim reimbursement.","I consent and authorize TPA/insurance company to seek necessary medical information from hospitals or medical practitioners.","I have included all bills/receipts for this claim and will not make any supplementary claim except pre/post-hospitalization claims."],"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/national-insurance/901-national-home-care-treatment-add-on-claim-form"}