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Hospitalisation Claim Form (Employee Id: 391877) Claim No: H0210190391877C001

This document summarizes a hospitalization claim form submitted by an employee for their child. The employee provided their and their child's details. The claim was for hospitalization at K M Speciality Hospital in Chennai from September 11-13, 2019 for acute gastroenteritis with mild dehydration. A total of 7 documents were submitted for the claim amounting to 18,204 INR. The employee agreed the information was correct and acknowledged disciplinary action could be taken if fraudulent.

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Seyed Billalgani
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616 views1 page

Hospitalisation Claim Form (Employee Id: 391877) Claim No: H0210190391877C001

This document summarizes a hospitalization claim form submitted by an employee for their child. The employee provided their and their child's details. The claim was for hospitalization at K M Speciality Hospital in Chennai from September 11-13, 2019 for acute gastroenteritis with mild dehydration. A total of 7 documents were submitted for the claim amounting to 18,204 INR. The employee agreed the information was correct and acknowledged disciplinary action could be taken if fraudulent.

Uploaded by

Seyed Billalgani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Hospitalisation Claim Form(Employee

Id : 391877)
Claim No : H0210190391877C001

Employee Details

Employee Id : 391877 Employee name : Seyed Billalgani Sathak Abdullah Ahamed

EmailId : seyedbillalgani.ahamed@tcs.com Mobile No : 9790000479

Patient Details

Name of Patient : Filza Ahban Gender F

Relationship : First Child Age 3

Hospitalisation Claim Details

All Hospitalisation claim should be raised within 90 days from the date of discharge

Type of claim : Hospitalisation

State : Tamil Nadu City : Chennai

Hospital Name : K M Speciality Hospital (No cashless for Hospital Address : No. 453/454, R,K Shanmugam Salai, K.K
PSUs) Nagar, Chennai - 600078

Date of Admission 11-Sep-2019 Date of Discharge 13-Sep-2019

Name of treating doctor : DR.S. VASANTH KUMAR MD., Details of illness/injury : Acute Gastroenteritis with mild dehydration
(PAED)DCH,

Medical Documents

Note: Please click on the check box 'Available' to update further details i.e. No.of Bills/Documents & Amount

Document Type Available No. of bills/documetns Amount

Original Discharge Summary 1

Original Hospital Main Bill 1 Rs.14702

Hospital Detailed/Break up Bill

Original prenumbered Cash Paid Receipt 1

Hospital Tariff Chart 1

Prescription for Medicine & Investigation 1

Original Investigation/Lab Report & Bill 1 Rs.1490

Original Pharmacy & Consulatation Bills 1 Rs.2012

Any other documents

Total no. of documents & claimed amount 7 Rs.18204

I will retain the scanned copies & submit the hard copies of all Original Medical bills and Documents with this claim form:

On Branch Address

02-Oct-2019 HIS Helpdesk - CHENNAI & HIS Helpdesk, Tata Consultancy Services Ltd., 185/188, Lloyds Road, Chennai ?
COIMBATORE 600086.

DISCLAIMER/TERMS OF AGREEMENT

All information provided in this claim form is true and correct. If it is found to be false and/or if it is proved that claim documents are manipulated then, I understand
and agree that TCS can initiate appropriate disciplinary action which may also lead to termination of my employment with TCS.

Date Employee Signature

Date of Submission

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