K.M.

MEMORIAL HOSPITAL & RESEARCH CENTRE

Bye Pass Road, Chas, B.S.City
Phone No :( 06542)-236188, 236189
E-mail:- kmmhrc@rediffmail.com
Web Site: www.kmmhospital.com

Date of Submission :- 27.10.2019

Name of the Patient :-

Age / Sex :- 38 YEARS / FEMALE

Referral S. No. :- 363

Address :- ALKUSHA,CHAS, BOKARO

Contact No. **********

Insurance No. :- 6015709561

Diagnosis :- BLEEDING PER VAGINAL

Condition of the patient at discharge :-

( For Package Rates)

Treatment/ Procedure done/ Performed

1. Existing in the package rate list's.

AMOUNT
OTHER IF NOT ON (1) AMT.
CGHS CODE / ADMITTED
S.NO. CHARGEABLE PROCEDURE PRESCRIBED CODE NO RATE CLAIMED REMARKS(X)
PAGE NO. (1) WITH
WITH PAGE NO WITH DATE
DATE(X)

2. ( Charge Rate ) For procedures done ( not existing in the list of packages rates )

AMOUNT
OTHER IF NOT ON (1) AMT.
CGHS CODE / ADMITTED
S.NO. CHARGEABLE PROCEDURE PRESCRIBED CODE NO RATE CLAIMED REMARKS(X)
PAGE NO. (1) WITH
WITH PAGE NO WITH DATE
DATE(X)

1 FIRST VISIT BY SPECIALIST 1 135X1 135.00

INVESTIGATION
2 HB 1389 18X1 18.00
3 TC 1390 31X1 31.00
4 DC 1391 31X1 31.00
5 RBS 1444 24X1 24.00
6 BLOOD UREA 1446 54X1 54.00
7 SERUM SODIUM 1481 50X1 50.00
8 SERUM POTASSIIUM 1482 50X1 50.00
9 CALCIUM 1466 60X1 60.00
10 CREATININE 1447 55X1 55.00
11 TSH 1562 90X1 90.00
12 HIV I AND II 1426 150X1 150.00
13 HCV 1425 128X1 128.00
14 HBS AG 1424 102X1 102.00
15 URINE ROUTINE 1383 35X1 35.00
16 USG FOR OBSTETRICS-ANOMALIES SCAN 1590 323X1 323.00
17 BLOOD GROUP & RHO TYPE 1418 30X1 30.00
18 V.D.R.L 1427 43X1 43.00
19 ECG 590 50X1 50.00
20 CLOTTING TIME 1401 32X1 32.00
21 BLEEDING TIME & CLOTTING TIME 1401 32X1 32.00
 22 ABDOMEN USG 1591 323X1 323.00
23 MT-10 TU-TU 50X1 50.00
24 LH 1563 150X1 150.00
25 FSH 1564 150X1 150.00
26 PROLACTIN 1565 150X1 150.00
27 URINE FOR HCG(PREGNANCY TEST) 1508 65X1 65.00
28 S.BILIRUBIN TOTAL & DIRECT 1456 80X1 80.00
29 GLUCOSE (FASTING & PP) 1465 47X1 47.00
30 E.S.R 1392 25X1 25.00
31 S.G.O.T 1476 55X1 55.00
32 S.G.P.T 1475 55X1 55.00
33 S.BILIRUBIN INDIRECT 20X1 20.00
34 CHEST X-RAY 1608 60X1 60.00
35 EXTREMITITIES BONES & JOINT AP & LAT 1611 255X1 255.00
36 SPINE AP & LAT 1616 250X1 250.00
37 ALKALINE PHOSPHATE 1494 60X1 60.00
38 LIPASE 1478 130X1 130.00
39 SERUM AMYLASE 1477 117X1 117.00
40 T-4 1561 64X1 64.00
41 T-3 1560 64X1 64.00
42 ANTI CCP 1555 450X1 450.00
43 DEXO SCAN BONE DENSITOMETRY WHOLE BODY 1715 2450X1 2450.00
44 PAP SMEAR 1437 150X1 150.00
45 ASO TITER 68X1 68.00
46 IVP (INTRAVENOUS UROGRAPHY) 1627 1190X1 1190.00
47 URINE CULTURE 100X1 100.00
Total 8101.00

3. Additional Procedure done with rationale and documented permission.

AMOUNT
OTHER IF NOT ON (1) AMT.
CGHS CODE / ADMITTED
S.NO. CHARGEABLE PROCEDURE PRESCRIBED CODE NO RATE CLAIMED REMARKS(X)
PAGE NO. (1) WITH
WITH PAGE NO WITH DATE
DATE(X)

Charges of Implant / device used …………N/A ………..

Amount claimed …Rs.8101/-, AmountAdmitted……………..Remarks.

Total Amount Claimed ( 2 ) Rs.8101/-.

Total Amount Admitted (x) ( 2 ) Rs…………………….

Remarks :-

Certified that the treatment / procedure have been done / performed as per laid down norms and the charges in
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.

Sign & stamp of Authorized Signatory with date

Sign/thumb impression of patient with date