Img 20240308 0001
Img 20240308 0001
Regd. & Corporate Office; 1, Nevu Tank Street, Valiuvar Koltam High Road, Nungambakkam, Chennai - 600 034.
xealth Corporate Office - Claims Dept. : l'1o.15, Balaji Complex, White$ Lane, 1st Floor, Royapettah, Chennai - 600 014.
& earieg lnsuEoce Toil lree Phone No: 1 800 425 2255 Toll tree Fax l{o: 1 800 425 5522
CIN : 16601CT1120t5PtC056649 Enail;suppod@siarirealtlr.h Website: B*w.sarhealth.in lRBAl Regr. No: 129
CLAI[/ . PART-A
TO BE FILLED lN BY THE INSURED Ihe issue of this Fom is not to be taken as an admission of liahility Claim I 052
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DECLARAT'OH BY TflE
'NSURED:
I hereby declare ihat the infonration furnished in this claim lornr is true & coffect to the besi of my knowlecige and Lrelief. if I have made any false or untrue statement.
medicai information ,'rjoCilments lronr any hospital / fuledical Practitioner who has attended on lhe person agaifst wlrom this claim is made. i hereby declare that I have m
included all the bills 1 receipts for the purpose of this claim & that I will not be making any supplementary claim except the prelpost-hospitalization claim, ii any- ()
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GUIDANCE FOR FILUNG CLAIM FORM - PART A {Te be filted in by the insured)
DATA ELEMEI'IT DESCRIPTION FORMAT
SECTIOI,I A. DETAILS OF PRTi'IARY INSURED
a) Pcircy No. Enter the policy nuorlter As allotted by'lhe insrrance cmpany
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I hereby declare that the infonnation'furnished in thls claim form is true & correci to the i:tesi of my knowledge and beliei. lf i have made any false or untrue statement,
suppression or c.fncealment of any material fact, my right 10 claim reimbursement shail be foi{eited. I also consent & authorize TPA / insurance company, to seek neDessary
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included all the bills / receipts for the pulpose of this 6laim & that I u/ill not be making any suppiementary claim except the prelposlhospitalizaliitn claim, if any. c}
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DATE 0F : 26.02.2024
ADMISSION TIME:05.35 PM
DATE 0F SURGERY : 26.02.2024 TIME:09.07 PM
DATE 0F DISCHARGE : 29.02.2024 TIME05.00 PM
PROCEDURE : EMERGENCY LSCS DONE
INDICATION PRIMI/ELDERLY SHORT GRAVIDA/USG FINDINDS OF CORD THRICE
AROUND THE NECK/MOBILE HEAD @ TERM IN LABOUR
CONSULTANT : DT.PAKKIALAKSHMI IOTHIGANESH M.D.(O.G).,DNB[o.GJ[MRCOG]
DR.HEMALATHA M.D.IPAED) DNB.,
DR.ARTVAZHAGAN M.D. IPAED).,
DR,SHANKAR M.D (Anesthesiology)
Under Spinal Anaesthesia abdomen was opened through SPT incision; LSCS
done in usual way an alive term BOY baby was delivered
which cried immediately; cord clamped & cut
, Inj.synto 20U added to the drip; placenta with membranes delivered in toto; uterus was closed with 1-
vicryl ;after perfect hemostasis secured;abdomen was closed in layers; clear urine draining at the end.
TREATMENT:
AIive 1. IVantibiotics
Term Inj.Piperacilin&Tazobactam 4.5gm
IV Bd
B BOY
Inj.Metronidazole 500mg Bd
A Baby wt:2.6kg Inj.Pantoprazole 40mg Bd
B 2. Analgesics
Y B/70,9/70 Inj.Paracetamol 100Omg IV Stat
Inj.Tramadol 5Omg IMStat
Inj.Promethazine 2Smg IM Stat
3. IE Prophylaxis given.
DATE: 26.02.2024
TIME: 09.07 PM
Mother blood group:B+ve
Baby blood group :0+ve
DISCHARGE ADVICE:
- Review after 1 weeks
- T. Ceffix 200mg (1-0-1)
- T. Metrogyl400mg (1-0-11 7 Days
- T. Aceclofix sp (1-0-1)
- Cap.Raberas D (1-0-1)
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pr. PAKKIA!5EIH J glstgiNEs
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Computerized Clinical Lab
No - 7, T.T l{agar, {st Street, {Near subalakshrni Pa!ace}, Karaikudi - 0 'l
Ref B;'. : PAy.K,ALAKSHIJII .tJD,OG i llllll llil ilIil ilfl illt ililt ilil ffr
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Towards
S,No Sample Test Details -Amount
1 BLOOD NIPT 16000
Total 16,000
Rupees sixteen thousand oniy I/lis.Cnarge 0
Less 0
Net Amount 16,000
Paid 16,000
Balance 0
Phone:9894331474
$"m[*skmi S*r&iiitrE {**tre
;*r'e,dr oqn $4,#iil osu,*ri,
MEDICINES
OTHERS
Total: 88093.00
Advance On 2610212024 20:42: 6500.00
Advance On 2710212024 18:51: 50000.00
Advance On 2910212024 19:02: 10000.00
Amount Receivable: 21593.00
Amount (in words): RUPEES rwENry-oNE rHousAND rve uuruohffi,6ffif{UHryE{qqqt,lT\f ,fiHf,jT$tffi
ONLY Amount Received: 21593.00
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Advance Receipt
Names ID Age Gender Mobile
Mrs. S.M.Sharmee S.Sudharsan LFC-9235 38 years F 9894823566
IP No: tL20
Authorized Signature
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Advance Receipt
Names ID Age Gender Mobile
Mrs. S.M.Sharmee S.Sudharsan LFC-9235 38 years F 9894823566
IP No: 7t20
Authorized Signature
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Advance Receipt
Names ID Age Gender Mobile
Mrs. S.M.Sharmee S.sudharsan LFC-9235 38 years F 9894823566
IP No: 1 120
Total 12887.72
Round Off 0.28
AmountTaxable 11550.14 GST 1336.98 CGST 668.49
Amount Receivable 12888.00
SGST 668.49
Amount (in words): RUPEES TWELVE THOUSAND EIGHT
Amount Received 12888.00
HUNDRED AND EIGHTY-EIGHT ONLY
C ENTRE
LAKSHill I FERTII-ITY
N;5, ciunct-l ?'nd STREET
T.T, I.JAG;\R
KARAII(utll - 630 00L
int https://mocdoc.irVstocks/print/bilVlakshmi-fertility-centre/location.
Krishnaa Phdrmacy
#S,Church 2nd St, TT Nagar, Karaikudi--630001
Phone:98943 3147 4
GSTIN: 33AAIHJ2736CZN
AmountTaxable 838.10 GST 41.90 CGST 20.95 SGST 20.95 AmountReceivatrle 880.00
Amount (in words): RUPEES EIGHT HUNDRED AND EIGHTY ONLY Amount Received 880.00
Total7520.23
Round Off (10.23
AmountTaxable 6795.19 GST 725.04 CGST 362.52
Amount Receivable 7520.00
SGST 362.52
Amount (in words): RUPEES SEVEN THOUSAND FM HUNDRED
Amount Received 7520.00
AND TWENTY ONLY
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630 001 -
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( at https://mocdoc.in/stocks/print/bilVlakshmi-fertility-centre/location.
Krishnaa Phdrmacy
#5,Church 2nd St, TT Nagar, Karaikudi--630001
Phone:989 4331474
GSTIN: 33AAIHJ2736CIZN
'$r?:3riliffiff#s \
KARAIKU}I'
LJt _ lrttps://mocdoc.inlstocks/print/bilVlakshmi-fertility-centre/location.
Krishnaa Phdrmacy
#S,Church 2nd St, TT Nagar, Karaikudi-630001
Phone:98943 31474
GSTIN: 33AAIHJ2736CZN
Total 81.42
Round Off (-)0.42
Amount Taxable 72.70 GST 8.72 CGST 4.36 SGST 4.36 AmountReceivable 81.00
Amount (in words): RIIPEES EIGHTY-ONE ONLY Amount Received 81.00
Krishnaa Phdrmacy
#S,Church 2nd St, TT Nagar, Karaikudi-630001
Phone:9894331474
GSTIN: 33 AAIlll27 3 6CIZN
Total 93.38
Round Off (-)0.38
AmountTaxable 85.48 GST 7.90 CGST 3.95 SGST 3.95 AmountReceivable 93.00
Amount (in words): RIIPEES NINETY-THREE ONLY Amount Received 93.00
H[::y-\[,Ht]lfJS#s-
rnnnir<uol - 630
oo'----
.
Pi* https://mocdoc.in/stocks/print/bill/lakshmi-ferlility-centre/[ocation..
Krishnaa PhdrmacY
#5,Church 2nd St, TT Nagar, Karaikudi--630001
Phone:989433147 4
GSTIN : 33AAIHJ2736CIZN
63.30 GST 7.60 CGST 3'80 SGST 3'80 Amount Receivable 71.00
AmountTaxable
Amount Received 71.00
Amount (in words): RUPEES SEVENTY-ONE ONLY
*5?l$\F"11llsIlJff
630 oOx
x.nnnir'tlul-
'int
-https://mocdoc.in/stocks/print/bilVlakshmi-fertility-centre/location...
Krishnaa Phdrmacy
#5,Church 2nd St, TT Nagar, Karaikudi--630001
Phone:98943 3147 4
GSTIN: 33AAIHJ2736CIZN
Total 137.20
Round Off (-)0.20
Amount Taxable 122.50 cST 14.70 CGST 7.35 SGST 7.35 Amount Receivable 137.00
Amount (in words): RUPEES ONE HUNDRED AND THIRTY-SEVEN
Amount Received 137.00
ONLY
Return Bill
Bill No: RETPHARM2324-387
Consultant: Dr. PAKKIAIAKSHMI M.B.B.S, M.D(OG)., DNB(OG) Datez 29/02/2024 12:17
NAME AGE GENDER MOBILE
MRS. S.M.SIIARMEE
LFC-9235 38 YEARS F 9894823566
S.SUDHARSAN
PAYMENT TYPE: AGAINSTIP PAYMENT DETAILS:
S.No Name Expiry Qty GST(%) Total
I RL 5OOML 31/10/2026 I 12.00 63.27
2 DNS 5OOML 3U10t2026 I 12.00 42.80
J EP 5OOML 30/05/2025 I 12.00 191.00
Total 297.07
Round Off (-)0.07
AmountTaxable 265.25 GST 31.82 AmountPayable 297,00
Amount (in words): RUeEES Two HUNDRED AND NrNEt.y_sEVEN oNLy
Amount Paid 297.00
PREPARED BY: Dhanalakshmi