NGI Claim

TO BE FILLED BY THE MEDICAL PRACTITIONER

1.Health Policy Number

2. Authorization Code

3. Patient Name:

4. Patient Date of Birth & Sex

Mobile No:

5. Nature of illness or injury

Acute

Chronic

Emergency

6. Are you patient's primary physician

Yes

No

7.Presenting Complaints

8. Duration of Symptoms:

9.Onset of Condition

10. Relevent Past Medical/Surgical History

11.Diagnosis:

ICD Code:

12.Etiology:

13.In case of Injury:mode of injury/place of injury:

14: Plans /Details of Management:

a. Procedures

CPT Code:

15. In case of Hospitalization :Date of Admission

Date of Discharge:

PRESCRIPTION WITH DOSAGE & DURATION

Date

Doctor's Name

Signature & Stamp

Physician Code

HNM Code

Authorization

Date

Signature of Insured/Claimant