Sl. Bill No. Date Amount Sl. Bill No. Date Amount
No. No.
1 RCA2445064 28/05/ 2015 200 6 RCA2448004 30/05/ 2015 200
(Please attach a separate sheet for more number of bills and receipts) TOTAL 25488.72
I/We hereby declare that the above details are true to the best of my/our knowledge and belief that I/We not suppressed any information
Claim form duly filled and signed Pre Hospitalization Bills & No(s)of Bills.
GHPL Pre-authorisation form Post Hospitalization Bills & No(s)of Bills.
Claim Notification Hospital Payment Receipt
Discharge Summary Investigation Report with Dr's request
Hospitalization Bills 1. MRI Yes/No 2. CT Scan Yes/No
Doctors Surgery Certificate if any 3. ECG Yes/No 4.X-ray Yes/No 5. US Scan Yes/No
Surgery / Consultation Bills if any Lab Reports with Dr's request No(s).of Rep
Medicines Bills with Dr's prescription Others if any