S from all the hospitals duly filled in are to be submitted. If admission to ICU is for more than one spell, details of such different admissions to be given separately) Name of the Patient Age In Patient No. Date of Admission in hospital Date of Discharge from hospital Date of Admission in ICU Date of Discharge from ICU Name of Attending Doctor / Surgeon Diagnosis Whether the present ailment/disease is a complication of any preexisting condition that the patient is suffering from? Past illness.
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How to fill out the Form Hihospital Treatment Rev 72009 online
Filling out the Form Hihospital Treatment Rev 72009 online can be a straightforward process when you know the steps. This guide will provide you with clear, concise instructions to ensure you accurately complete the form for health insurance policies related to hospital treatment.
Follow the steps to complete your form accurately.
- Press the ‘Get Form’ button to acquire the form and open it for editing.
- Begin by entering the patient's name in the designated field. Ensure it is spelled correctly, as this will be crucial for identification.
- Fill out the age of the patient and their in-patient number, if applicable. These details help to track the patient's treatment history.
- Provide the dates of admission and discharge from the hospital. This information defines the duration of the hospitalization.
- If applicable, enter the dates of admission and discharge from the Intensive Care Unit (ICU). Specify if there were multiple admissions to the ICU.
- Include the name of the attending doctor or surgeon, ensuring their details are accurately recorded for verification.
- Indicate the diagnosis and whether the present ailment is a complication of any pre-existing conditions, providing additional details as necessary.
- Outline the patient's past medical history, including any previous illnesses or surgical procedures that could impact current treatment.
- Record the time of admission and discharge for both the hospital stay and ICU, if applicable.
- If the ailment is linked to a previous surgery or condition, specify the details of this connection.
- Describe the nature of the treatment received. This should include details on surgery performed (if any) and its duration.
- For accident cases or road traffic accidents, specify if the patient was under the influence of alcohol, if it is a medico-legal case, or if a First Information Report (FIR) was lodged.
- Fill in the hospital details, including the name, registration number, and the number of in-patient beds.
- Confirm the hospital's capabilities, such as fully equipped operation theatres and ICU units, along with the availability of qualified medical staff.
- Attach a copy of the patient's health ID card or a photocopy of a recent passport-sized photograph, ensuring it is attested by hospital authorities.
- In the certification section, the hospital authorities must provide confirmation of the patient's hospitalization and treatment details, including the place and date, followed by their signature and seal.
- Finally, review your completed form for accuracy, then save your changes. You may choose to download, print, or share the form as needed.
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