1. This document appears to be a bill submitted by Tie-up Hospital to ESIC (Employee State Insurance Corporation) for reimbursement for medical services provided. 2. It includes details of a cataract surgery performed on a patient named Vallavan R., including diagnosis, treatment provided, costs claimed, and certifications that cashless treatment was provided according to the agreement between the hospital and ESIC. 3. The total amount claimed is Rs. 15,175 and various forms are included as required documentation for the bill to be processed by ESIC, such as discharge records, referral documents, and patient satisfaction certification.

1. To be used by Tie-up hospital (for raising the bill0 (P-II)
(NABH accredited/Superspeciality Hospital)
(Attach documentary proof)
Date of Submission: 15/11/2012
Individual Bill Format
Name of the Patient : Vallavan R. Referral S.No. (Routine) /
Emergency/through / SSMC/
SMC : 959732
Age / Sex : 48 / Male
Address : 151 P Ambethkar Colony,Samsikapuram,
Rajapalayam,Virudhunagar.
Contact No : 7373514634
Insurance Number/Staff
Card No/Pensioner Car No : 959732
Date of referral : 8/11/2012
Diagnosis : Left eye Nuclear Scelerosis cataract Grade II
Condition of the patient at
discharge : Good
Photograph
Of the
patient
verified by
hospital

2. (For Package Rates)
Treatment/Procedure done/
performed :
I. Existing in the package rate list's
CGHS/other Code no/nos for chargable procedures :
S.No Chargeable
Procedure
CGHS
Code no
with
page
no (1)
Other if
not on (1)
prescribed
code no
with page
no
Rate Amt.
Claimed
with date
Amount
Admitted
with date
(X)
Remarks
(X)
1 LE--
Immature
cataract
127` - 9375 9375
10/11/12
- -
Charges of lens Rs. 5800/-
Amount Claimed Rs.15175/- Amount Admitted Remarks
(To be filled by ESIC official(s)

3. II. (Non-package Rates) For procedures done (not existing in the list of packages rates)
S.No Chargeable Procedure Amt. Claimed
with date
Amount Admitted with
date (X)
Remarks
(X)
- - - - -
III.Additional Procedure Done with rationale and documented permission
S.No Chargeable
Procedure
CGHS
Code no
with page
no (1)
Other if not
on (1)
prescribed
code no with
page no
Rate Amt.
Claimed
with date
Amount
Admitted
with Date
(X)
Remarks
(X)
- - - - - - - -
Total Amount Claimed (I+II+III) Rs.15175/-
Total Amount Admitted (X) (I+II+III)
Remarks
Certified that the treatment/procedure has been done/performed as per laid down norms and the charges
in the bill has/have been claimed as per the terms & conditions laid down in the agreement signed with
ESIC.
Further certified that the treatment/procedure have been performed on cashless basis. No money has
been received/demanded/charged from the patient/his/her relative.

4. Sign/Thumb impression of patient with date Sign & Stamp of Authorized Signatory with date
(for Official use of ESIC)
Total Amt payable:
Date of payment :
Signature of Dealing Assistant Signature of Superintendent
Date: Signature of ESIC Competent Authority (MS/SMC/SSMC)
1. Discharge slip containing treatment summary & detailed treatment record.
2. Bills(s) Implant(s)/ Stent(s)/device along with Pouch/packet/invoice etc.
3. Photocopies of referral proforma, Insurance Card/Photo I card of IP/Referral recommendation
of medical officer & entitlement certificate. Approval letter from SMC/SSMC in case of
emergency treatment or additional procedure performed.
4. Sign & Stamp of Authorized Signatory.
5. Patient/Attendant satisfaction certificate.
6. Document in favour permission taken for additional procedure/treatment or investigation.
(X) to be filled by ESIC Official(s).

5. (P-V)
Monthly Bill Special Investigations For diagnosis centres/referral Hospitals
Bill No IP/ 16864 Date of Submission 15/11/2012
S.No Name of
the
Patient &
Insuranc
e/Staff
no
Date of
Reference
Investigation
Performed
CGHS/ot
her code
no with
page no
Charges
not in
package
rates list
Amount
Claimed
with date
Amount
Admitted
(entitled)
with date
Remarks
Disallowances
with reasons
- - - - - - - - -
Certified that the procedure/investigations have been done/performed as per laid down norms and the
charges in the bill has/have been claimed as per the terms & conditions laid down in the agreement
signed with ESIC.
Further certified that the procedure/investigations have been performed on cashless basis. No money
has been received/demanded/charged from the patient/his/her relative.
The amount may be credited to our account 01238110000034 no RTGS HDFC 0000123 no
and intimate the same through email/fax/hard copy at the address.
Date: Signature of the Competent
Authority of Tie-up Hospital
Checklist
1. Investigation Report of each individual/Pt.
2. Copy of Referral Document of each individual/Pt.
3. Serialization of individual bills as per the Sr. No. in the bill.
It is certified that total amount of Rs has been credited to your account no.
, RTGS no on
Signature of Account department with stamp.
Date: Signature of Competent Authority
Referral Hospital.

6. (To be filled up by ESIC official(s) )
Patient Referral No
PATIENT/ATTENDANT SATISFACTION CERTIFICATE (P-VI)
1. I am satisfied/not satisfied with the treatment given to me/ my patient and with the
Behavior of the hospital staff.
2. if not satisfied the reason thereof.
3. It is stated that no money has been demanded/ charges from me/ my relative during the
Stay at hospital.
Date & Time: 10/11/2012 Sign/Thumb impression of patient/Attendant
Name of the Patient :Vallavan R.
Name of IP : General Ward
Insurance No/Staff no: 959732
Date of Admission : 09/11/2012
Date of Discharge : 10/11/2012

7. To be used by Tie-up hospital (P-III)
Consolidated Bill Format
Bill No.IP/16864 Date of Submission : 15/11/2012
Bill Details (Summary)
(1)
S.No
(2)
Name
of
patient
(3)
Ref.
No
(4)
Diag./
Procedure
for which
referred
(5)
Procedure/
Performed
/treatment
given
(6)
CGHS/
other
Code
(with
page)
No/Nos/
N.A
(7)
Other
if not
in
CGHS
rates
list
(8)
Amount
claimed
with
date (X)
(9)
Amount
entitled
with
(10)
Rema
rks
(X)
1 Vallavan 959732 LE- Immature
catarect
Phaco with
IOL
127 - 15175 - -
Total Claim. Rs. 15175/-
Certified that the treatment/procedure has been done/performed as per laid down norms and the charges
in the bill has/have been claimed as per the terms & conditions laid down in the agreement signed with
ESIC.
Further certified that the treatment/procedure have been performed on cashless basis. No money has
been received/demanded/charged from the patient/his/her relative.
The amount may be credited to our account on 01238110000034 RTGS no 0000123 and
intimate the same through email/fax/hard copy at the address.
Date: Signature of the Competent
Authority of Tie-up Hospital.
Checklist
1. Duly filled up consolidated proforma.
2. Duly filled up Individual Pt Bill. Proforma.
Certificate: It is certified that the drugs used in the treatment are in the standard pharmacopeia
IP/BP/USP.
It is certified that total amount of Rs___________________ has been credited to
your account no._____________, RTGS no__________________on______________
Date: Signature of the Competent Authority.
III.to be filled by ESIC Official(s).
The Photocopy to be sent to Tie-up Hospital by Ms/SMC/SSMC.