All Medicare C73ac3dea5

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Where to Submit the claim

INHOUSE Health Claims Processing HUB TATA AIG General Insurance Company Limited, H.No 7-1-6-617/A, 5th and 6th Floor, Imperial
Towers, Door No 615,616, Ameerpet, Hyderabad 500016, Telangana.
How to track the claim

Step-1 Open www.tataaig.com and click on Self Service
Step-2 Login & choose search claims
Step-3 Track claim status with the help of Policy Number/Member ID/ Claim Number
Please submit complete documents as per the check list for speedy claim settlement.
CLAIM DOCUMENTS SUBMITTED-CHECK LIST

S.No. Document Yes No Type of document
1. Copy of cancelled cheque for the proposer- Account holder’s name, account number and
IFSC code should be printed on the submitted copy
2. If the claimed amount is more than 1 Lakh; CKYC Form along with Photograph + PAN Card
Copy of the Proposer + Address Proof
3. Claim form _ Please fill all the mandatory fields with appropraite information
4. Tata AIG Health Card or Policy Copy
5. ID, Address & Age Proof of the patient & Proposer
6. Discharge/Daycare Summary from the hospital indicating the presenting complaints,

diagnosis, treatment given and Past medical history
7. Hospital Finall Bill with breakup of the individual items of the bill
8. Proof of payment paid at hospital - cash receipt
9. In case of Implants being used - Please share relevant Invoice & Sticker
10. Pharmacy & lab Bills
11. Diagnostic/lab Reports for submitted bills
12. Doctor Prescriptions for submitted pharmacy bills
13. Previous medical records and Consulation papers prior to hospitalization
14. Any previously approved settlement letter from other insurance (if any)
15. In case of accidental injuries, pleas submit Medico Legal Case (MLC) /First Information
Rreport (FIR)
16. In case of death of main member, details of nominee (as per policy schedule), along
withaddress & ID proof of nominee.
17. Hospital reigistration certificate
Type of Claim:
In-Patient Treatment Day Care Procedures Health Checkup High End Diagnostics
OPD Treatment – Dental Maternity Cover Restore benefits OPD Treatment
Daily Cash for choosing Shared Accommodation Pre & Post-Hospitalization expenses
Toll Free No. (24x7): 1800 266 7780 OR 1800 229966 (For Senior Citizens)  Email: customersupport@tataaig.com
IRDA of India Registration No: 108  Website: www.tataaig.com  CIN: U85110MH2000PLC128425 | MediCare Premier Old UIN: TATHLIP21257V022021
MediCare Premier New UIN: TATHLIP23167V032223  MediCare Old UIN: TATHLIP21224V022021  MediCare New UIN: TATHLIP23118V032223
MediCareProtect UIN: TATHLIP21225V022021  Medicare Plus UIN: TATHLIP21253V022021
CLAIM FORM
(Part -A)
To be filled in by the insured. The issue of this Form is not to be taken in as admission of liability
Please fill-up this form in CAPITAL LETTERS
DETAILS OF PRIMARY INSURED (*Mandatory fields) (SECTION A)
Policy No*:
Company Name*: Tata AIG GIC Ltd.
Prefix First Name Middle Name Last Name

Name*:
Address*:
Registered E-mail id*
Registered Phone Number* /
DETAILS OF INSURANCE HISTORY (SECTION B)
i. Currently covered by any other Mediclaim/Health Insurance: Yes No
ii. Have you been hospitalized in the last four years since inception of the contract? Yes No
Date: Diagnosis: _________________________________________
iii. Date of commencement of first insurance without break:
If yes, Company Name:
Policy No: Sum Insured (Rs.):
iv. Previously covered by any other Mediclaim/Health Insurance: Yes No
If yes, Company Name:
Policy No: Sum Insured (Rs.):
DETAILS OF INSURED PERSON HOSPITALIZED (SECTION C)

Name:
Gender: Date of birth: Age Years Months
Relationship to Self Spouse Child Father Mother

Primary Insured:
Other (Please Specify)
Occupation: Service Self Employed Homemaker Student Retired
Other (Please Specify)
DETAILS OF HOSPITALIZATION (SECTION D)

Name of Hospital:
where Admitted
Room Category occupied: Day Care Single occupancy Twin sharing 3 or more beds per room
Hospitalizaton due to: Injury Illness Maternity
2
Date of Admission: Time:
Date of Discharge: Time:
Substance Abuse/Alcohol Consumption
If Medico legal: Yes No
Reported to police: Yes No
MLC Report & Police FIR attached: Yes No (If yes, attach report)
System of Medicine
DETAILS OF CLAIM (SECTION E)
Details of the treatment expenses claimed: Details of Lump sum/cash benefit claimed:
Type of claims Total expenses Type of claims Total expenses
In-Patient Treatment Critical Illness
Pre & Post-Hospitalization expenses Accidental death benefits
Day Care Procedures
Health Checkup
Daily Cash for choosing Shared Accommodation
OPD Treatment
OPD Treatment – Dental
Maternity Cover
High End Diagnostics
Grand Total
DETAILS OF BILLS ENCLOSED: (SECTION F)
Sl. No. Bill No. Date Issued by Towards Amount Total

1
10
Please provide the reason for delay in submitting the documents

(Post 30 days from Date of Discharge)
DETAILS OF PRIMARY INSURED BANK ACCOUNT: (SECTION G)
PAN:
Account No:
Bank Name and Branch:
Cheque/DD Payable details: IFSC Code:
Please provide a Cancelled cheque of Proposer (with printed payee Name)
DECLARATION BY THE INSURED (SECTION H)

I hereby declare that the information furnished in this Claim Form is true & correct to the best of my knowledge and belief. If I have made any false
or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim
reimbursement shall be forfeited. I also consent & authorize TPA/insurance company, to seek necessary medical information/documents from any
hospital/Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills/
receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.
Date: Signature of the Insured
Place
(PART-B)
To be filled in by the Hospital. The issue of this Form is not to be taken as an admission of liability. Please include the original preauthorization
request form in lieu of PART A
Please fill-up this form in CAPITAL LETTERS
DETAILS OF HOSPITAL (SECTION A)

Name of the Hospital:
ROHINI ID:
Type of Hospital: Network Non Network (If non network fill section D)
Facilities available in the hospital: OT: ICU:
Name of Prefix First Name Middle Name Last Name

the treating
Doctor:
Phone No.:
Registration No.:
(with State Code)
DETAILS OF THE PATIENT ADMITTED (SECTION B)

Name of the
Patient:
IP Registration Number: Gender: M F Age: Years Months
Date of Birth: Date of Admission: Time:
Date of Discharge: Time:
Type of Admission: Emergency Planned Day Care Maternity
If Maternity: i) Date of Delivery: i) Gravida Status: G P A L
Status at time of discharge: Discharge to home Discharge to another hospital Deceased

Total claimed amount `:
DETAILS OF AILMENT DIAGNOSED (PRIMARY) (SECTION C)
ICD 10 Codes: Description ICD 10 PCS: Description

i) Primary Diagnosis i) Procedure 1
ii) Additional Diagnosis ii) Procedure 2
iii) Co-morbidities iii) Procedure 3
iv) Co-morbidities iv) Details of Procedure
Pre-authorization obtained: Yes No Pre-authorization Number:
If authorization by network hospital not obtained, give reason:
Hospitalization due to injury: Yes No
i) Substance abuse / alcohol consumption
ii) If injury due to Substance abuse/alcohol consumption, Test Conducted to establish this: Yes No (If Yes, attach report)
iii) If Medico legal: Yes No iv) Reported to Police: Yes No v) FIR No.:
vi) If not reported to police give reason:
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (SECTION D)
(ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
Name of the Hospital:

Address:
City/Town District
Pin Code State
E-Mail Phone
Registration No:
Hospital PAN: Number of Inpatient beds:
with State Code
Facilities available in the hospital: i) OT: Yes No ii) ICU: Yes No iii) Others
DECLARATION BY THE HOSPITAL (SECTION E)

(PLEASE READ VERY CAREFULLY)
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any
false or untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited.
Date:
Place Signature and Seal of the Hospital Authority
TAGIC Health Claims,TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,
GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone-040-66864900Toll Free: 1800 266 7780 or 1800 229 966
(For Senior Citizens)Website: www.tataaig.com; Email: healthclaimsupport@tataaig.com
Prohibition of Rebates - Section 41 of Insurance Act, 1938 as amended by Insurance Laws (Amendment)
Act, 2015
1.
insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable
or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate,
except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.
Insurance is the subject matter of solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully, before concluding a sale.
Part C - Know Your Customer (KYC)
With reference to IRDAI Circular No. IRDAI/SDD/MISC/CIR/135/07/2016,
KYC details are required for Individual/ Retail policy holders, if the total claimed amount exceeds `100,000
CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual
Important Instructions:
A) Fields marked with ‘*’ are mandatory fields. G) List of State / U.T code as per Indian Motor Vehicle Act,
B) Tick ‘ ’ wherever applicable. 1988 is available at the end.
C) Please fill the form in English and in BLOCK letters. H) List of two character ISO 3166 country codes is available
D) Please fill the date in DD-MM-YYYY format. at the end.
E) Please read section wise detailed guidelines / I) KYC number of applicant is mandatory for
instructions at the end. update application.
F) For particular section update, please tick ( ) J) The ‘OTP based E-KYC’ check box is to be checked for accounts
in the box section number and strike off the opened using OTP based E-KYC in non-face to face mode
sections not required to be updated.
For office use only Application Type* New Update

(To be filled by financial institution)
KYC Number (Mandatory for KYC update request)
Account Type* Normal Minor Aadhaar OTP based E-KYC

(in non-face to face mode)
1. PERSONAL DETAILS* (Please refer instruction A at the end)

Name* Prefix First Name Middle Name Last Name
(Same as ID
proof)
Maiden Name
Father /
Spouse Name
Mother Name
Date of Birth* Gender* M- Male F- Female T-Transgender
Pan* Form 60 furnished
2. PROOF OF IDENTITY AND ADDRESS* (Please refer instruction B at the end)

I. Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital KYC process needs to be submitted
(anyone of the following OVDs)
PHOTO*
- A- Passport Number
- B- Voter ID Card
- C- Driving Licence
- D- NREGA Job Card
- E- National Population Register Letter

- F- Proof of Possession of Aadhaar
II. - E-KYC Authentication
III. - Offline verification of Aadhaar
Address
Line 1*
Line 2
Line 3 City / Town / Village*

District* Pin / Post Code*
State / U.T Code* ISO 3166 Country Code*
3. CURRENT ADDRESS DETAILS (Please refer instruction B at the end)
Same as above mentioned address (In such cases address detail as below need not be provided)
I. Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital KYC process needs to be submitted
(anyone of the following OVDs)
- A- Passport Number
- B- Voter ID Card
- C- Driving Licence
- D- NREGA Job Card
- E- National Population Register Letter

- F- Proof of Possession of Aadhaar
II. - E-KYC Authentication
III. - Offline verification of Aadhaar
IV. - Deemed Proof of Address - Document Type code
Address
Line 1*
Line 2
Line 3 City / Town / Village*

District* Pin / Post Code*
State / U.T Code* ISO 3166 Country Code*
4. CONTACT DETAILS (All communication will be sent to Mobile number/ Email-ID provided)
(Please refer instruction C at the end)
Tel. (Off) - Tel. (Res) -
Email ID Mobile
5. REMARKS (If any)
6. APPLICANT DECLARATION
• I hereby declare that the details furnished above are true and correct to the best of
my knowledge and belief and I undertake to inform you of any changes therein,
immediately. In case any of the above information is found to be false or untrue or [Signature / Thumb Impression]
misleading or misrepresenting, I am aware that I may be held liable for it.
• I hereby consent to receiving information from Central KYC Registry through Signature / Thumb Impression of Applicant
SMS/Email on the above registered number/email address.
Date: Place:
7. ATTESTATION / FOR OFFICE USE ONLY

Documents Received Certified Copies E-KYC data received from UIDAI Data received from offline verification
Digital KYC Process Equivalent e-document Video Based KYC
KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS
Date Name
Emp. Name Code
Emp. Code
Emp. Designation
Emp. Branch
[Institution Stamp]
[Employee Signature]
CENTRAL KYC REGISTRY | Instructions / Checklist / Guidelines for filling Individual KYC Application Form
A Clarification / Guidelines on filling ‘Personal Details’ section

1 Name: The name should match the name as mentioned in the proof of Identity submitted, failing which the application is liable to be
rejected.
2 One of the following is mandatory: Mother’s name, Spouse’s name, Father’s name.
B Clarification / Guidelines on filling ‘Current Address details’ section

1 Incase of deemed PoA such as utility bill, the document need not be uploaded CKYCR
2 PoA to be submitted only if the submitted PoI does not have current address or address as per PoI is invalid or not in force.
3 State/ U.T Code and Pin/Post code will not be mandatory for Overseas addresses.
4 In Section 2, one of I, II, and III is to be selected. In case of online E-KYC authentication, II is to be selected.
5 In Section 3, one of I, II, III and IV is to be selected. In case of online E-KYC authentication, II is to be selected.
6 List of documents for ‘Deemed Proof of Address’.
Document Code Description

01 Utility bill which is not more than two months old of any service provider (electricity, telephone, post-paid mobile
phone, piped gas, water bill).
02 Property or Municipal tax receipt
03 Pension or family pension payment order(PPOs) issued to retired employees by Government Departments or
Public Sector Undertakings, if they contain the address
04 Letter of allotment of accommodation from employer issued by State Government or Central Government
Departments, statutory or regulatory bodies, public sector undertakings, scheduled commercial banks, financial
institutions and listed companies and leave and licence agreements with such employers alloying official
accommodation.
7 Regulated Entity (RE) shall redact(first 8 digits) of the Aadhaar number from Aadhaar related data and documents such as proof of
possession of Aadhaar, while uploading on CKYCR.
8 “Equivalent e-document” means an electronic equivalent of a document, issued by the issuing authority of such a document with its
valid digital signature including Intermediaries Providing Digital Locker Facilities) Rules, 2016.
9 ‘Digital KYC process’ has to be carried out as stipulated in the PML Rules, 2005.
C Clarification/ Guidelines on filling ‘Contact details’ section

1 Please mention two-digits country code and 10 digit mobile number (e.g. for Indian mobile number mention 91-9999999999).
2 Do not add ‘0’ at the beginning of the Mobile number.
D Clarification/ Guidelines on filling ‘Related Person details’ section

1 Provide the KYC number of a related person, if available.
E Clarification on Minor
1 Guardian details are optional for minors above 10 years of age for opening of bank account only
2 However, in case guardian details are available for minors above 10 years of age, the same (or CKYCR number of guardian) is to be
uploaded.
List of two – digit state / U.T codes as per Indian Motor Vehicle Act, 1988
State / U.T Code State / U.T Code State / U.T Code

Andaman & Nicobar AN Himachal Pradesh HP Pondicherry PY
Andhra Pradesh AP Jammu & Kashmir JK Punjab PB
Arunachal Pradesh AR Jharkhand JH Rajasthan RJ
Assam AS Karnataka KA Sikkim SK
Bihar BR Kerala KL Tamil Nadu TN
Chandigarh CH Lakshadweep LD Telangana TS
Chattisgarh CG Madhya Pradesh MP Tripura TR
Dadra and Nagar Haveli DN Maharashtra MH Uttar Pradesh UP
Daman & Diu DD Manipur MN Uttarakhand UA
Delhi DL Meghalaya ML West Bengal WB
Goa GA Mizoram MZ Other XX
Gujarat GJ Nagaland NL
Haryana HR Orissa OR
List of ISO 3166 two- digit Country Code
Country Country Country Country Country Country Country Country

Code Code Code Code
Afghanistan AF Dominican Republic DO Libya LY Saint Pierre and PM
Miquelon
Aland Islands AX Ecuador EC Liechtenstein LI Saint Vincent and the VC
Grenadines
Albania AL Egypt EG Lithuania LT Samoa WS
Algeria DZ El Salvador SV Luxembourg LU San Marino SM
American Samoa AS Equatorial Guinea GQ Macao MO Sao Tome and ST
Principe
Andorra AD Eritrea ER Macedonia, the MK Saudi Arabia SA
former Yugoslav
Republic of
Angola AO Estonia EE Madagascar MG Senegal SN
Anguilla AI Ethiopia ET Malawi MW Serbia RS
Antarctica AQ Falkland Islands FK Malaysia MY Seychelles SC
(Malvinas)
Antigua and Barbuda AG Faroe Islands FO Maldives MV Sierra Leone SL
Argentina AR Fiji FJ Mali ML Singapore SG
Armenia AM Finland FI Malta MT Sint Maarten SX
(Dutch part)
Aruba AW France FR Marshall Islands MH Slovakia SK
Australia AU French Guiana GF Martinique MQ Slovenia SI
Austria AT French Polynesia PF Mauritania MR Solomon Islands SB
Azerbaijan AZ French Southern TF Mauritus MU Somalia SO
Territories
Bahamas BS Gabon GA Mayotte YT South Africa ZA
Bahrain BH Gambia GM Mexico MX South Georgia and GS
the South Sandwich
Islands
Bangladesh BD Georgia GE Micronesia, FM South Sudan SS
Federated States of
Barbados BB Germany DE Moldova, Republic of MD Spain ES
Belarus BY Ghana GH Monaco MC Sri Lanka LK
10
Belgium BE Gibraltar GI Mongolia MN Sudan SD
Belize BZ Greece GR Montenegro ME Suriname SR
Benin BJ Greenland GL Montserrat MS Svalbard and Jan SJ
Mayen
Bermuda BM Grenada GD Morocco MA Swaziland SZ
Bhutan BT Guadeloupe GP Mozambique MZ Sweden SE
Bolivia, Plurinat onal BO Guam GU Myanmar MM Switzerland CH
State of
Bonaire, Sint BQ Guatemala GT Namibia NA Syrian Arab Republic SY
Eustatius and Saba
Bosnia and BA Guernsey GG Nauru NR Taiwan, Province of TW
Herzegovina China
Botswana BW Guinea GN Nepal NP Tajikistan TJ
Bouvet Island BV Guinea-Bissau GW Netherlands NL Tanzania, United TZ
Republic of
Brazil BR Guyana GY New Caledonia NC Thailand TH
Britsh I ndian Ocean IO Haiti HT New Zealand NZ Timor-Leste TL
Territory
Brunei Darussalam BN Heard Island and HM Nicaragua NI Togo TG
McDonald Islands
Bulgaria BG Holy See (Vatcan City VA Niger NE Tokelau TK
State)
Burkina Faso BF Honduras HN Nigeria NG Tonga TO
Burundi BI Hong Kong HK Niue NU Trinidad and Tobago TT
Cabo Verde CV Hungary HU Norfolk Island NF Tunisia TN
Cambodia KH Iceland IS Northern Mariana MP Turkey TR
Islands
Cameroon CM India IN Norway NO Turkmenistan TM
Canada CA Indonesia ID Oman OM Turks and Caicos TC
Islands
Cayman Islands KY Iran, Islamic Republic IR Pakistan PK Tuvalu TV
of
Central African CF Iraq IQ Palau PW Uganda UG
Republic
Chad TD Ireland IE Palestine, State of PS Ukraine UA
Chile CL Isle of Man IM Panama PA United Arab Emirates AE
China CN Israel IL Papua New Guinea PG United Kingdom GB
Christmas Island CX Italy IT Paraguay PY United States US
Cocos (Keeling) CC Jamaica JM Peru PE United States Minor UM
Islands Outlying Islands
Colombia CO Japan JP Philippines PH Uruguay UY
Comoros KM Jersey JE Pitcairn PN Uzbekistan UZ
Congo CG Jordan JO Poland PL Vanuatu VU
Congo, the CD Kazakhstan KZ Portugal PT Venezuela, Bolivarian VE
Democratc Republic Republic of
of the
Cook Islands CK Kenya KE Puerto Rico PR Viet Nam VN
Costa Rica CR Kiribati KI Qatar QA Virgin Islands, British VG
Cote d’Ivoire !Côte CI Korea, Democratic KP Reunion !Réunion RE Virgin Islands, U.S. VI
d’Ivoire People’s Republic of
Croata HR Korea, Republic of KR Romania RO Wallis and Futuna WF
Cuba CU Kuwait KW Russian Federaton RU Western Sahara EH
Curacao !Curaçao CW Kyrgyzstan KG Rwanda RW Yemen YE
11
Cyprus CY Lao People's LA Saint Barthelemy BL Zambia ZM
Democratic Republic !Saint Barthélemy
Czech Republic CZ Latvia LV Saint Helena, SH Zimbabwe ZW
Ascension and
Tristan da Cunha
Denmark DK Lebanon LB Saint Kits and Nevis KN
Djibout DJ Lesotho LS Saint Lucia LC
Dominica DM Liberia LR Saint Martin (French MF
part)
12

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PLUS

Where to Submit the claim

How to track the claim

CLAIM DOCUMENTS SUBMITTED-CHECK LIST

4. Tata AIG Health Card or Policy Copy

5. ID, Address & Age Proof of the patient & Proposer

6. Discharge/Daycare Summary from the hospital indicating the presenting complaints,

8. Proof of payment paid at hospital - cash receipt

10. Pharmacy & lab Bills

11. Diagnostic/lab Reports for submitted bills

12. Doctor Prescriptions for submitted pharmacy bills

13. Previous medical records and Consulation papers prior to hospitalization

17. Hospital reigistration certiﬁcate

OPD Treatment – Dental Maternity Cover Restore beneﬁts OPD Treatment

DETAILS OF PRIMARY INSURED (*Mandatory ﬁelds) (SECTION A)

Company Name*: Tata AIG GIC Ltd.

Preﬁx First Name Middle Name Last Name

Registered E-mail id*

Registered Phone Number* /

DETAILS OF INSURANCE HISTORY (SECTION B)

i. Currently covered by any other Mediclaim/Health Insurance: Yes No

Date: Diagnosis: _________________________________________

iii. Date of commencement of ﬁrst insurance without break:

If yes, Company Name:

Policy No: Sum Insured (Rs.):

iv. Previously covered by any other Mediclaim/Health Insurance: Yes No

If yes, Company Name:

Policy No: Sum Insured (Rs.):

DETAILS OF INSURED PERSON HOSPITALIZED (SECTION C)

Gender: Date of birth: Age Years Months

Relationship to Self Spouse Child Father Mother

Occupation: Service Self Employed Homemaker Student Retired

Other (Please Specify)

DETAILS OF HOSPITALIZATION (SECTION D)

Date of Discharge: Time:

Substance Abuse/Alcohol Consumption

If Medico legal: Yes No

Reported to police: Yes No

DETAILS OF CLAIM (SECTION E)

DETAILS OF BILLS ENCLOSED: (SECTION F)

Sl. No. Bill No. Date Issued by Towards Amount Total

Please provide the reason for delay in submitting the documents

DETAILS OF PRIMARY INSURED BANK ACCOUNT: (SECTION G)

Please provide a Cancelled cheque of Proposer (with printed payee Name)

DECLARATION BY THE INSURED (SECTION H)

Date: Signature of the Insured

DETAILS OF HOSPITAL (SECTION A)

Name of Preﬁx First Name Middle Name Last Name

DETAILS OF THE PATIENT ADMITTED (SECTION B)

If Maternity: i) Date of Delivery: i) Gravida Status: G P A L

Status at time of discharge: Discharge to home Discharge to another hospital Deceased

DETAILS OF AILMENT DIAGNOSED (PRIMARY) (SECTION C)

ICD 10 Codes: Description ICD 10 PCS: Description

Pre-authorization obtained: Yes No Pre-authorization Number:

If authorization by network hospital not obtained, give reason:

Hospitalization due to injury: Yes No

i) Substance abuse / alcohol consumption

vi) If not reported to police give reason: