10-Aug-22 Date : Mrs. KISHORI GAJBHIYE for 60436 /- Dear Esteemed Partner, Greetings form Apollo Hospitals Navi Mumbai -ROHINI Registration No - 8900080348257, we are proud SR. NO 3 ' a / For enquires, appointments contact: 022 - 3350 3350 11066 Regd. Office: Apollo Hospitals Enterprise Limited, No. 19, Bisnop Gardens. Rsja Annamalaipuram, Chcnnu 60D 028. CIN I 851 1l)TNr/7?Pl.aCB035 Apollo Hospitals. Pio: #'3, Pars k Hill Ruud. OP Uran Road. Sr-ctor - 23, CBD Belapur. Navi M.mbai 400 616. Mahoroihlr.i, Inci. I T t-91 2? 3350 3350 I Fax No -91 ?? 27533080 I Emergency No. 1066 T. infoia3pollohoscitals.com I mumbai.apcllohospitBls.com For online appointment: •.sw.v.askapoila.com Keep the records carefully and bring them along during your next visit to our Hospital To, HDFC ERGO GENERAL INSURANCE CO LTD 1 2 SUB JECT: Submission of IPD Credit Bill ofPatlent:. BILL NO: ANM-ICR-64010 Swift Code Branch & Code NA NA NA NA NA NA YES YES YES YES HDFCINBBXXX ________ NerulBranch, Ccae-D2S8 _________ 4 _________ 5_ _________ 6 _________ 7 S 9 _________ 10 _________ 11 _______ 1£ We are providing Credit Facilities ATTACHED / NA (Not Applicable} YES ~ NA to be associated with your esteemed organization and wish for endless mutually beneficial relations. We enclosed herewith the Credit bill for the captioned patient along with the below mentioned documents for your kind perusal. We request you to process and pay the same within agreed credit pe fi o°^ DETAIL ise Ltd, Navi Mumbai 1 Ernail Id :j;ecjcyab!e_nm@.ai)ollohospi;als.com:.74 30916285 f Off Uran Road,Sector -23, CBD Belapur, Opp. Nerul Wonder Park. Navi Mumbai • 430614 Apollo ■HOSPITALS Ori ginal Approval letters __________ _ Copy of Insurance ID card cf patient. / policy paper ___________ ___ Copy of Photo ID prof with address proof of patient. Or policy h older ______ ______________________________ _ _____________ Copy of Pre authorization form. ____________________ _ ______ Original Implant sticker along with bulk purchase letter. Breakup of the package. ___________________________________ Medical justification for prolong stay ____________________ Claim Form part B. _________________________ ________________ Original Sum mary bill with patient's signature. Original Detail bill breakup. __________________ ___________ Original Discharge summary. ________________________________ All original reports. ____________________________ __________ L O1C ..... only to selected corporate clients like you. We request you to settle the bills on or before 30 days from the bill received date. Any delay in full and final settlement of above claim within the specified period w.ll attract interest of 17.5% P-A (as per the Bank Interest). The Acc ount Holder Name Account No. ________ IFSC Code __________ Bank Name ________ Branch Address payment can be made through fund transfer, our NEF1 / RTG S detail am as below APOLLO HOSPITALS ENTERPRISE LIMITED-COLL 50200019326382 _______ ___________ HDFC0000258 HDFC Bank Ltd ___________________ Co ral Crest Plot No-3, Sector 23, Near Nerul Railway Station, Nerul (E), Mumbai-400706 _____________ _ Kindly send us the settlLent details on the below mentioned add,«, / Email address. For any query in the said bill please (eel free to contact the under signed. Rdrtoeeco/ni ApbtexHospitals Ei^ft Vy O, '-1 IMP BILL CHECKING GUIDELINES MOU DISCOUNT APPLIED AND SHOWN IN SUMMARY AND DETAIL BILL, PLEASE CALCULATE BILL ACCORDINGLY Dear Team, The bill checking guide lines are as follows please refer the same in connection with the example below. C. amount as it will result In double discount from your end. MEO'C.'lfc ce No.-.O ” T in>v Sptc.phty Nam*" B.d NO Admisnon Dal* Aulliotltaiion No CREDIT Btiivw ’ yp* D.SonjrcF TFAiCorpcral-lll N»t Arnounl Grote Amount 51. P 50' Of Ot>0 '.V.r-I “ -al'.-soy a84 >: < "'AGC 00 is rc- Rix I, '45 fC 00 r.nrt I ’ rJVrt - I 305 DO ■ 05 OE • 530.00 Riot' • e os 'n •iOS '0 c ViO OG 2.044 50 joj eo 2 350 OC <* ^n»UIW ’ .pn 2.500 CO CO ae.nw'.sxat'o- 5 29.890 23 3.2zo.eo iuH Tutjl 26 E JO 2 Antmint Afl.r MW Di^counl o CO B-ALREDY APPLIED MOU DISCOUNT Tutil Discount Auliiuoiaiton Amoun((t| • 35S SC C NLI BILL AF1 LR MOU DICOU^ 15.25U CO C«h 0, NonC4»t> I525S Deposit 1152'0) RvfuiwJ I) -4 032 35 Net Arnounl SIXTH FvGOft E AARD Me I i O ’ AUDAWD) A. The final bill without MOU discount is A which you should take as CLAIMED AMOUNT. B. The applied MOU Discount is B which you should take as MOU DISCOUNT already applied. The net amount claimed after application of MOU discount is C, please DO NOT take this amount as claimed oe- ’ i<5..20 ” u.ie.e? AM 5 50 1 08 approval and settlement, ce NOV 2D' ' • ’ '4 ’ 0 AM Kindly note that we are following IRDAI instructions and accordingly we are applying and showing the MOU discount in the summary AND details bill therefore you are requested to calculate the bill properly for Final A-C (AIMED AMOUNT.GROSS Bl I i^> ?E cc.co ^*33.161 l>5 I HDFC ERGO General Insurance Company Limited '1^.- a Cashless Enhancement Letter Claim Number : RC-HS22-13103258_1 (Please quote this number for all further correspondence) Date : 0$i08J2022 Authorization Is valid for admission up to 20/08/2022 HDFC ERGO General Insu'ance Company Limited Seif Details of Patient Gencer Female KISHORI PRAKASH GAJBHIYE ^atifint Name 01. , 08f2022 Policy Number 2805203716327501 ExfXiCied Date of Discharge : 05 ( '0a2022 21. ’ DC* 2021 To 20.'OCT>2022 °olicy Punod Estimated ength of stay 5 Proposed lino of treatment : Conservative Respralory o.f-order, unspeofiec Provisional Diagnosis Authorization Details Amount Status Reference Number Date & Time Pre Au th Approved 70534 RC-HS22-13!03258 1 05-08-2022 12 32 24 Total Authorized amount : Rs 70534 /- ( Seventy Thousand Five Hundred Thirty Four only ). Note-Previous authorisation stand cancelled Hospital Agreed Tariff Authorization Summary : 70534 ( NR ) Total Bill Amount : 0 ( INR ) •Other Deduct ons : 0( NR ) Discount 0( NR ) Cc-Pay i O-INR i Zonal Co-Pay : 0( NR ) Deductioies 70534 ( NR ) Total Authorised Amcont :0(NR) Amount to be paid by Insured Age 66 yrs Expected Date of Admission : HDHO ERGO Ganarnl nsirnrce Comsany Lh tsc. IHDAI Reg No 146 CIN. U6E037MH20C ’ 7H.C 177117. Rcnsturad 8 Corciu'alu Cfllw: 1 ft 6 her HHoLSe. IS&'iee Backtay Re=lamator H I I ’ a-ekh Varg, Chirrhgalc, Mumbai - «U 1)20 Authorization Remarks : Covered for active medical management requiring hospitalization only. Non medical expenses including expenses for PPE kits to be collected from member. Claim will be settled as per tariff irrespective of approved amount. Room category - as per pre auth request form. The final bill amount shall be generated as per the MOU (Memorandum of Understanding) for discount and tariff rates. Non-compliance would warrant the recovery of excess amount. : KISHORI PRAKASH GAJBHIYE • ER2 117535669-0 IE Dear SirMadam This has reference to the pre-autborizatrnn request submitted on 05/08/2022 'A'c hereby aulnerizc cashless facility as per details ment-oned below To. APOLLO HOSPITALS ENTERPRISE LIMITED. NAVI MUMBAI PLOT-13. PARSIK HILL ROAD. OFF URAN ROAD. „ NAVI MUMBAI.MAHARASHTRA. 4UC614 Contact No. -022-3350335(1. ROhinl Id 8900080348257 Room Category Eligible rcom category 3S per T & C of Policy Ccnt'act Name of InSuriinccCompariy Name of TPA Proposer Name Patient's Member ID.TPA.'Insure- id of Patient Rc'aton with Proposer II. Non-package Case : i. Room Renb'day i ICU Renb ’ day - i NursingCharges<'day u. Consultant Visit Charges/day v Surgeon's fee/OTAraesthetisL ... vl. Others (specifyI I.Packagc case : Agreed package C.istcmor Service AiUreSS D 331,3rd Floor, Ea-.lem BusircM Oixlricl (Magi el Mali:. 183 M»-g. bnand.ip RYnsl). Muriiei • 4C0 076. CMinner Service he •91 22-92346234>9- -120 62M 62$< I wa -. v ndfc^onm HDFC ERGO General Insurance Company Limited o- Other Deduction Details Sr no. Description Bill Amount I Package 7C534 0 70534 Terms and Conditions of Authorization 2.KYC (Keo.v yco* customer) details of proposerfemoloyee^Beneficiary aru mandatory 'ur claim payout above Rs I lakh 7.Dfferential Costs Mme by po icyhoWer may be reimbursed by insurers subject to the terms and ccndifcns of the policy. DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM 1. Detailed Discharge Summary and al Bills from the hospital 2. Cash Memos from tne Hospitals : Chemists s^ppcrlcc by proper prescriplion. 4, Su'geoo's Certifcale staing nature o'operation parformed and Surgeon ’ s Bill and Receipt 5. Certificates from attending MeCrcat Practillonbr ■ ’ Surgeon giving patient ’ s condition and advice on discharge. Name of the Product Optima Restore and UINNp - Important Pol icy temrs & conditions (sub-lim its,'co-pay/deductible etc) POINTS TO BE NOTED BY INSURED IN SUPPORT OF THE CLAIM Dear Customer, If you had paid any bill amount to the hospital apart from the non-payable items, copayment or deductible, Please submit your claim form for reimbursement along with bills and payment receipts. 4,Nftl7.ork Provider snail no: make any recovery from tne deposl arncunl collected from Insured exuepl 'nr costs towards nan-admissible amountsfindudlng additional charges due to cptng higher room rent Iran eligibility.' choosing separate line of treatment v.hch is not envisaged.'ccnsiderec in package). I.CasHass Aulhorizalon letter issued on the basis of Information provided ir Pre- Authonzat on form. In case misreproscntal on'conccalmcnt of Inc facts, any material diTererce.' deviation' 1 discrepancy in infcrmailpn is Observed m discharge summary? IPD records then cashless authorization slrall stand null & void. Al any point of da m processing Insurer ur TPA reserves right io m se quenes for any other document to asteria n admissibility of Calm J.Network provder snail net collect any additions amount ’ rem tne lnd limlf chfjKan miCB-UcIk. fir, oi C-x-pjiWoofn-u MFaU-i IH.EASE CQVF.E'E C€CLAJWX« 3F 'HIS FORMl 5)Cxltc , .Nir>t>i< at Na-t o' iM r^ln; Oxer ci : u -sxncl:rc5c-ianHil *)P vo ,, ju - i D»?W» hiCDCwa: ,i Nm RkpMic liBiliro'i i.! brttir.oia- pi P7©x«tl I ne ol 'jOBTntiil I: aotm*-v id^rin-atn I) J iii^r.Ui'a-eo! i.rqir, M rutywor i. Eetroii'DcoKe IjiR-A.' ’ ’ ei i Byucl rtuy L tto (i!ncMncl*:*e-t IIIotaJ rtrxil }<; TwiiwciKlsfl ftKUpimUi! •« *« Na Faterrt ^.s-- Fattxi vW I'lflpD Ij-Deo R$. R; Hl r> : fix '0-ciw* n Of PATIENT TO BE FILLED BY INSU- fO BE FILLED BY TREATING DOCTOFVHOSPtTAL Z! Gi/J 'BH. f F ik ::»M ’ » i i >; Cunjrl^ ’ JTMCf tmwWPswn: b| [ I-.WII 15 xndiWLfcdal Us-^O-'trl ;iC,t»C«a/s Hi Rs. HDFC ERGO Cl N9M» nl l|-e:s«' D>e«« "Hi -WttfJpjlXITftMlli || Io: -''lu-mimpiu'de Midi * i 4 nd R li fL£Xk X <>. H in«Sar«: Rs. Rs. R4 i;fa>l-itLv.yp^n; *ln:!:d .os o'DHwiv OsUlli of pKonl lOmHlotf i: tisowsrg^ ;Un^hwtil»i®ft <««* ’ : oiSilo.Wx.clsi,*Va, rfoipU. CtSjshKM: 1 |0tt> r; = k Osf Twn Rrl • Nuirg A Sir>t8 CW (|£«WJM :»:n» n^fjitcr.- dKoMlw , (iICVO'O-x,! WC T CMoi i; awBsMnJ ert 3.«; om -AjiesTe-.si I m ; • -o'(utaionCmio« r| K' omiiw • CcowraClH • ecu 9l lirciiim :i KP «hk! M»i4 »pcc f,i niWrtrtr.'*^ pocmes ||Mr \ 0| » ixti ms px ojd ea-y>* F a-r, opJcito (gy y PlSmTaa » i| tBir:D«aio IfiHjptffliacn i Na b FIRN?: !, I ------ 1 — {.CiFWlj * -a. ru.BM.kViJUa-Hsaifi rsum-w *» O N ’ p 0 Fl Ci IfcTCJtNo ITC N aRA C 1 T^s u f-A N C LI TTLZrr 07 S ’ C uj II ci 'Z ’ alrl 1 Hsn» R SW ’ suib b. D. 0 r. ilt .liLreCfS Nflnie:. B = --n,Ti| Id lopGt-Wl; b cl K ‘ PM -cj iTtf Out* Q DECIARATH HOSPITAL DECLARATION JjI'ldC'. ’ 1 ' ;i'3uiue. vu dlb^e-lhv •• ?M co-n-i -a/n? reK irdmKcd rd a| Sa-ocl'J^lTOlTDCO.IX c. K: A'. ablcn !>■ ■•. <11 ■- nr.i cor'innU>-.:onr.bliiui'r ’ < ji .xliujjOdib" lie- V.- contim ihui no recovorrtn, *•. WJUillMI lHi.tc-4 1 1 11 i r~rn H^CSRj^'Cfl'R-l injfv: -i • >-•■ 1 M.rU-i-a> l«U C.-/U ■■>;<'.>:: .'4. •. ■ ' -' ‘ I ■ " S? mgMbsr/;.'.'^< .-AMbJw.O ‘ X> • Vai: L.-i.U-< CT] I T1 cj R w ,r * “ r ' N d * ,: " D -e.pl* SoilPuiUKbX CW?2II!'I ^l.|..> 7 a i0rClMr 1 I^GCW e ---, 1KPAII«K^ • • ..wG .HbHvl^ll^luina-oibup^nentir.hcb.^-M^. ’ th.s^^dd^^^ \ U. t irsuw i< u-.^ 93 oi .Vj<<-4d ^aor-ajc R«es ox.^pl «8H •.iwalx -0Mdini»lbk , b - tol -S ,11.0 Ndtwrt PfiNtar) aivS.'ar:a«>• ••«»*■ “ “ “ « O .. ............ ............... ™ «. »>.«.. e, h n. », w. »»»~™ no, fSJrtZ,' «X?;, kv / ■. .«■ ~ — • ’ « I — «■«««» ■ ’ PA,.l.no,» u -.™«in :l ,« 1 ,, BM r.i«.r..,« M[! P,. i wital* 'I ' ' ‘ ‘ S Ir , ejp3C10 ,d | agree lbs: rfl have m-.de <;< shell mn.e any -also o- untrue sWcnent. eup^iur or •|Va ia ur«riro'.- ’ -rsrceCom|. ’ -.contaam^i^'.r-o-ghrrabtareniaiilororyuideleonih^ciain. 11 sh OR | pMrASH 61A4&H i'1± _______________________ KE Wo Wve no o& ( ott«n w a -.^^ 1S s.,e d M OT e 3EM o^o M c l .^s.« l s 8 ne 0 o< U ^ Form submitted to us. Please visit ouf website m network hcsptals please v “ u We value your relationship with us ana assure you " °X you. ^e.ed u™. Id l. policy is pu^as^h.^^ _ ______ __ .................... , Hon-asun auou! our Company Gnowroo nondllng and any «hw supart. « »»- «» 01 « \7s7th^\\vw'hdfcerca.com'Our-!iospilals4 ’ eMrxk.3SDx our best services at all tmes and we Icok forward to serve you. Certificate for the purpose of deduction urn | Intermediary Code 2011B0146310 I ider Section 80 D of Income Tax Act, 1961* - ■ - has p Bl d Rs.36535 (Rupees THIRTY-SIX THOUSAND FIVE £INDRED THIRTY-FIVE) 'sued to MS KISHORI PRAKASH GAJBHIYE for penod 21-Oct-2021 to 200=1-2022. iviniWiiiiiiiBiiiiiiiiJiuiiiii ;wa»mWM ’ »5 ■Note ----- I Intermodia7 Conta ct Numbe r i I 9004815420 I No ’ 91 ZZ-KM&M •■91-I23 5234 6234 l-cTerjiWii HDFC ERGO General Insurance Company Limited Policy Schedule - Optima Restore Individual | Place o-' Supply | Policy Issuance Date | 30f09/2021 Zl/IOZZOIfi 9004815420 Details Member 6 Member 5 Member 4 Member 3 Membe' 2 Particu ars I Member D Name Member ID Nc-. 202001 CO021 63173 2020010002163178 .m awff,E< i <7- - I 1 KISHORI PRAKASH GAJBHIYE KISHORI PRAKASH GAJBH V E HDFC ERGO ~'|Intermedi ary Contact No __________ _________________________ Harmonized System Of Aaldent and Health msurance NomondatureCode Serv.ces.9971 I P erson Nam e [K ISHORI PRAKASH GAJBHIYE 2786.5 2786.5 0 0 Date o f B4n (Ag a) ________ Relationship tu Policy Holcer Baso Sum Insured?) Multiplier B en efit SI (? > Protector Rider Sum Insured (7) TcialSum Insured ft) _____ _ iNomln ec Details [Nomine e N ame : Ms Paya] Gajbhlye [The nominee must bean i. .. lation (?) Policy Number Policy Holder's Name Pc&cy Ho ’ de's Address Policv Holder Stale Name & C qcb GSTIW UiN (if any) of Policy HoKle- _________ _ -Irst polcy Inception date ■ — ------ Policy Perlcd ---------------- Prom 00:01 hrs on 21/1 0 /2021 To 24:00 hra on 20/10 /2022 Issuing/Ser.'lcinc Office GSTIN EIA Number intennediary Name Intermediary Code iCTOOflO Other Rlttere and Benefits (X) Protector Rder __________ _________ ~ Hospital Daily Cosh Rder SI (Max. 30 da ys) ________________ _________ Critical Advantage Rider S ’ IPARxjerSI _________ [Nornln.cc Details — __ ------- ~ Reiabonshlp to Policyholder Daughter ^ediat< ‘ (Native c! tha policyholder. For all other Insured Persons ±o policy hoktor sha ” bemo nomtnee. THANE 27AABCL5O45N 1 Z8 ____ __ ____ ________- SA'ATI BHIMSEN DHONDKAR '261190146010 2B147|CGST@9% ___________ 0 |SGST I UTGST@9% ___________________ 2 814.74 IGST@O% 28147 ■ Any otny Cess or ~axes _______________ 36535 | Rupees Tnir.y-Six Thcusarid Frve Hundred Thirty-Five Certificate No. CSD/67..202 1/2096 Gated 24.'C6.2C21. N: '9122-62346234< S' -120 5234 6234 *w- hdfcer^.wn 1 Member 1 KISHORI PRAKASH GAJBHIYE/ 20200'0002163178 ' 25/07/19 5 6 (65) Self 500000 500000 ilo ab M g .-* Mc rnbe' ID N o of Insur ed 2020010002163178 W Premium Discour is Loadings Taxab ’ e Premium G ross P'cn.um ________ Gros s Preri.jifi I in words i ______ _______ file Starr c duty of Rs. 1/-( Rupees Ore Only 1 pad Origins : -'cr RedpienV Duplicate mr Suup: er Whe ther tax is payable on reverse ch ai.-ie basis No ___ Refer the leaiiJtaHafi Exclusion Type 2805 2037 1 632 7501 00 0 -------- ------- -------- -------------------------- Ms Klshori Prakash Galbhiye _______________ _________ ____________ _ ______________ — - — ,-,.,7, ------ n FLATNO 88 BULDING NO B-15 KENDRIYA VIHAR SECTOR 38 NEAR D-MART Neml West Navi Mumbai NAVI MUMBAI MAHARASHTRA-4CO7O6 r.. ----------------- Maharashtra S 27 [Place o-'Supply [MAHARASHTRA --------------- For Rs 50C0C0(Rupaes Five Lakhs) I [Sec 5 A (1) and Sec 5 A (ti) Sec 5 A (iii) of the policy word-ng Is waived. [ For Rs 5C0C0C< Rupees Five Lakhs) ISecS A (I) and Sec 5 AW Sac 5 A ,(41) of the policy wcrdir.g .-s waived. | | Loac m g Reason __________________________ _________ — 'Th s policy is being charged adcitonal p remium for Medical Con ditjca | Appkabie | Health Condition [Exclusion on SI Duration (Years) HDFC ERGO General Insurance Company Limited Policy Schedule - Optima Restore Individual it «AX^{ Claim Admlnistra'.or : HDFC ERGO GENERAL INSURANCE COMPANV LTD "lot dcuilcd policy Icnut und comliiioi ilcasc visit our wcbt u Location: Mumbai Date: 3009.2021 HDFC ERGO For and on behalf of HDFC ERGO General Inaurartce Company Limited Authorized Signatory l-OFC ERGO Insurance CtxWimned RDAI Reg NO.146CIN : J66CWH»J7P l C17?117. & Corporate C- “ «: Itt Flocc. HDFC Hcv^. 16S.T66 Rec^kn Ojichgaw. Mu-naai -4WC23 UN: HD W.IP21322VCC2O21 Cutter Sor.«Mm 5 :0 30 ’ 3rd Fleer. Easier) Business Dsiflcn, Magnet Mel). LBSMara. &^ndup;\?est! MurWal-lCWS.CusloirarServw Nj : *9t 22«?M62M'•9V20CZj462M**V'.n3t»-gc com h ’ U'S' •.'ww'V hdlccrao ctimritiiwnki.iij. ’ ntilit.'v-wordir.gs" HDFC ERGO General Insurance Company Limited PoBcy No.: 2805203716327501000 k Gen^r Femae miured Namo KBkriPrattihGBpnyi HDFC ERGO Na : ‘ 9122-62346234 .'•B<-12OK>*82M *w/.nifC9rgo.am 7emB and Conditon* 0| Thl. ca-d would bo ««lld tin your roUtonahlp with HDFC ERGO Gonoral Inauranca Company Uimitod7hi8 card la Inrand it lha policy la canwllad (2} In can of ranawal plow, rotor oiiglnsl policy number (3j Tns card » wued tcrrw putpoM cfidontifcaUj't ant, and dees nd aniai aulcmo'jc tatAKS ‘ Killy al ha ner-ort. hcspilal. W A ptolo ID BsuMbyanygc/ar-meni authcrlly is io ba pxcvcrJ to ■>»! cssAass toily. I5j Pease ef»y tor cssh'ouladlly « nura prer IB admisson r case of plsmad admishnt and .linn 2* hours d dd-tsticn h cssa c»6fW7nr,.i8| *1 Inrn orc condito-s d th: pd»3 «wd to ap?taK>e wile prxesars your cashew «uwt. I?) In rasa yojr rashWs '*illy s ceniadcba h any reason, pleaw'Abmltteclam V reimturssmenl Denalol cashfaH tsalty dees nol rdcale '^eclon ol tK> dahi. !8) Pease r&» wlcy cccuireiitscsrafufY for oaialfedteors and ccnclnns. For claim slav.a vail nab saclicn on cu -etecew.wklccrvo.arr. ajhrir.nvet, you rev -rto W « al HMbvJalTOSJhdfW'COCCir HCFC ERGC Ganara :r5jn><;e Conoany Lmlnfl. IR3AI Heg No.l^ CIN W6333MH2C0TPLC'77117 Resisted & Ccwraa Office: ’ st Hour, HDFC House, 165-'£6 Beckray Redarobon, H '.Pa-ekh Mur j ChurchGew WjmM, - *» 323. Heeth Odm Ser.ices Addrosr, : HDFC ERGO Gwarai b-swana- Cc^cev.. Unnod Staler IT Park. To-nr- ’ $?■ =.»'. C - 26. toca Seclor62 231331, UlUrFiodasx Se v>» to. 022-82M623A' 0123F«2346234Emal: naahnd&msghcfcerspwm.Irara lc$: dWayod »3.S toiBflfis io HD'C lid arc ERGO Irtematonal AG and taed by Iha Ccrpcn, under lonsa GSTIN : 27AAACA5443N2ZH Reference No : Bill To(1> ; - ANM 1.0000181067 UHID : Mrs. KI SHOR I GAJBHIYE Name : IP Number: ANMIP94642 llllllllllllllllllllllllllllllillllllllllll Pan Number : Bill No : ANM-ICR-64010 Time: 14:58:18 Date RC-HS22-1 3103258 Billing Type : 01 -Aug-2022 22:40:58 Admission Date : 05-Aug-2022 11:26:04 Discharge Date HDFC ERGO GENERAL INSURANCE CO LTD Gross Amount 15,760.00 2 264.00 3 0.00 4 5 168.00 6 7 8 0.00 Pago 1 of 10 For enquires, appointments contact: 022 “ 3350 3350 Spouse Name Address Doctor Name Speciality Ward Name Bed No 1,267.00 1,400.00 28,800.00 4,432.11 9,240.00 7,435.00 2,200.00 3,456.00 0.00 1,232.00 25,344.00 4,432.11 9,240.00 6,542.80 1,936.00 1.267.00 : PRAKASH GAJBHIYE : B-15-88, KENDRIYAV1HAR, SECTOR 38. NERULWEST Navi Mumbai Maharashtra India, Cell No:91-9892787510 ft tuexst-t- 11066 : 05 -Aug -2022 iniiniiiiiiiiniiiiiiiiiiiiiinio'iiii Employer Name: SL. No — i Amountf?) 13,868.80 MOU Discount 1,891.20 892.20 In Patient Bill - Bill of Supply Age: 66Yr OMth 11 Days Sex: Female TPA/Corporatc(1): HC?C E:,G0 GENERAL INSURANCE CO LTD (GSTIN-.) Regd. Office: Apollo Hospitals Enterprise Limited, No '9. fiishep Careens Ra.a Annamalaipuram, Chennai - f.00 023. CIN L85' IQT'JI 979PLC08035 Apollo Hospitals, ^.c! #13, Parslk Hill Road. OH U'an Road, S'- lot - 23 C8D Selapur, Nav Mu-bai iOO 614. M ih,ir.isht-.a. India I T: -91 22 3350 3350 I Fa« No.: •?' 22 27533080 I Emergency ho.. 1066 C: 'nloiri.ipn' nhosp.ta.s.com I mumbai.aoollohospilait. com For online appointment: w»V4V.askapollo.corr XfHh Keep the records carefully and bring them along during your next visit to our Hospital Apollo Apollo ■ hospitals Service Consultation(999311) lnvestigatlons(999311) Medical Administratlon(999311) Hospital services (others)(999311) Profile(999311) Room Rent(999311) Ward Pharmacy(999311) Medical Sorvices(999311) Dr.VAlSHALI LOKHANDE INTERNAL MEDICINE SEVENTH FLOOR H WARD 7008 (SINGLE) ____________ CREDIT Authorization No; ANM-ICR-64010 ANMIP94642 Namo : Mrs. KISHORI GAJBHIYE Bill No: IP No : 70,534.11 | 6,671.40 Sub Total Service Amount Authorization Amount(1 ) HDFC e RGO GENERAL IN jj UK m N vc CL/LIU ibbllN-) 60,436.00 Mr. reshAlwar Nadar Mr. Surest) Alwar Nadar Generated By as Disclaimer : For enquires, appointments contact: 022 - 3350 3350 PAN NO:AAACA6443N * TAN N0:>AUrAA^9E03B ' ROHINI ID :89M08')34S2!>7 * HOSPITAL REGISTRATION NQ:287 Online Payment access- https J/pay.apoltohospItals.com 'All the above dates indicated as Date & Time of the entry only I fl 066 u/ Signature Of Patient/Attendant Regd. Office: Apollo Hospitals Enterprise Limited, No ■ 9. 6 shop Gardens Ra a Annamalaipuram, Chennai - cOO 022. CIN L35' 10TN1979PLS08035 Apollo Hospitals, njat AI3, “ arsik Hill Roed. OH Oran Rood, Sector - 23 C3D Selapur, Nav Mumbai-4U(J 614. M ih.i.p.-t-.i, India I T; -91 22 3350 3350 Fax No.: 22 27533080 I Emergency No : 1046 C ahaspitals.com I mumbai aDol.ohospila.s com For online apcointmem: www.askapollo.co- Keep the records carefully and bring them along during your next visit to our Hospital Apollo ’ (CashiO.OO, NonCash:0.00) (Cash:0.00, NonCash:1 0,000.00) 63,862.71 63,862.71 To Pay _________________________________________ Deposit (3811123) Refund (382331 5,EFT.3823290,CASH) ______________ Net Amount Payment Details: Amount in words : ? Sixty Thousand Four Hundred Thirty-Six Only No Tax is Payable on Reverse Charge Basis Payment Details: Refunded ? Six Thousand Five Hundred Seventy-Three Only to Mrs. KISHORI GAJBHIYE 3,427.00 10,000.00 6,573.00 60,436.00 J?' ’ ,, Apollo ■HOSPITALS MepMan Name : Mrs. KISHORI GAJBHIYE ANMIP94642 Bill No: ANM-ICR-64010 IP No: Payer Payable Amount^ 1 2.400.00 -12 2.112 00 1 02>'08<2022 1 2.400 00 -12 2,112 00 2 1053759 IP VISIT CHARGES (SINGLE) 20:00 4,224.00 Dept Sub Total : 1 -12 2.112.00 0308'2022 1 2/00 00 10:00 -12 2.112.00 1 2/00 00 2 1055759 IP VIST CHARGES (SINGLE) Dept Sub Total : 4,224.00 1 2/00.00 -12 2.112.00 1 0'..'08'2022 1 2/00.00 -12 2,112.00 2 1058759 IP VISIT CHARGES (SINGLE) 10:00 1.267.00 05. , 08.'2022 1 1,267.00 0 1 10 00 Page 3 of 10 Disclaimer ; For enquires, appointments contact: 022 - 3350 3350 i i i i i Service Name ( Order No. ) Alias Code Qty/Duration ( in mins ) Dept Sub Total : Dept Total : Dept Sub Total : Dept Total : 4,224.00 12,672.00 1,267.00 1,267.00 SL. Service No Code Hospital services (others)(999311) 05-Aug-2022 Medical Services 3024146 BED-GST 03-Aug-2022 Consultation 1055759 IP VIST CHARGES (SINGLE) 04-Aug-2022 Consultation ■ 058759 IP VIST CHARGES (SINGLE) 03'08'2022 16:00 02'08'2022 3 00 04. , 08' , 2022 9:00 Start Date 11066 Regd. Office: Apollo Hospitals Enterprise Limited, Nr. 19. Eiahcp Careens, Raia Annamalaipurarr, Chennai - 400 028. CIN L85110TN1 ?79PL0Dffl)35 Apollo Hospitals, Plot .'TJ, Parsik H ll Road. OH U- jii Road. Sector - 23. CBD Selapur, Navi Mu-bai .•.00 614. Maharashtra, InBia I T: -91 22 3350 3350 I Fax No.: -9 ’ 22 27533080 I Lmv-gi-nr,' No 1046 E nloiaaEO'.'. ohospitai.s.com I m.mbai.asollohospilnu. i or For onl ne app&int'rtien?: vv.v.vaskapolh.com ■ '"i Keep the records carefully and bring them along during your next visit to our Hospital Apollo I >r**' Dr Name 1C55759 Df.VAISHALI LOKHANDE (INTERNAL MEDICINE) 10557S9 Or. VAISHALI LOKHANDE (INTERNAL MEDICINE) lnvestigations(999311) 01-Aug-2022 BioChemistry "All the above dates indicated as Date & Time of the entry only 1058759 Dr. VAISHALI LOKHANDE (INTERNAL MEDICINE) 1058759 Df.VAISHALI LOKHANDE (INTERNAL MEDICINE) 1058759 Dr. VAISHALI LOKHANDE (INTERNAL MEDICINE) 1058759 Dr. VAISHALI LOKHANDE (INTERNAL MEDICINE) Reference Dis (%) Tariff Consultation(999311) 02-Aug-2022 Consultation 1058759 !P VIST CHARGES (SINGLE) End Date Apollo ■ hospitals • 12 3 640.03 -12 3.203.23 5133 1 2 5133 4,584.80 Dept Sub Total : 490 03 • 12 431 20 1639 1 1639 431.20 Dept Sub Total : •12 906 40 1224 1 030.03 1224 Dept Sub Total : 906.40 484 00 550.03 -12 794 794 1 2.310.00 0 2 310.00 2,310.00 Dept Sub Total : 1 2.310.00 0 2.310.00 2,310.00 Dept Sub Total : 2.31C 00 0 2.310 00 1 1 2,310.00 Dept Sub Total : 2.310.00 1 2.310 00 0 1 •All the above dates indicated as Date & Time of the entry only Page 4 of 10 Disclaimer : For enquires, appointments contact. 022 ” 3350 3350 02-Aug-2022 BioChemistry C-REACTIVE PROTEIN (CRP) XRay BED SIDE X-RAY CHEST AP 01/0&2022 22:40 03'38'2322 22:40 Dept Sub Total : Dopt Total : Dept Sub Total : Dept Total : 484.00 6,406.40 2,310.00 9,240.00 04-Aug-2022 Medical 1077592 Hcspila' Services and Treatment Momlor ng and Managere' ’ .) Cha'ges CARDIOLOGY ECG Ol/Ca.'2022 22:49 O1.*CS.'2C22 22:44 O2'C8. ‘ 2C22 0 23 04 1 '08 1 '2D22 22.40 11066 Profile(999311) 01 -Aug -20 22 Lab Others 02-Aug-2022 Medical 1077592 Hospitd Services and Treatrrenl Mortlcrlng and Management Charges 03-Aug-2022 Medical 1377592 HospitS Servicas and Treatment Monitoring a- d Management Charges O1.'C3.'2C22 23:19 D2<'38 , 2O22 22:40 Regd. Office: Apollo Hospitals Enterprise Limited, N-. 19, Bishop Garders. Raja Annamal jipuram, Chen-a - 630 029. CIN: L851 i0TM?7 ’ PL0:B035 Apollo Hospitals, Plot 11'3. Pars k Hill Road. Off Uran Road. Sector 23, CBD Uelapuf, Navi M.mibai-400 614. Maharashtra. India IT •?! 22 3350 33:0 I Fax No >91 21 27533060 I Fmergenc/ No.. 1066 E: in'oEapDllo-ospitcls com I muinb.i apDllohospitals.com For online appcmlment: wwaskapoth.com Keep the records carefully and bring them along during your next visit to our Hospital Apollo Bill No ; 1.570.03 ANMIP94642 O1.'C8.'2C22 23:19 Name : Mrs, KISHORI GAJBKIYE 1076161 HS T'oponin I - Plasma Medical Services(999311) 01 -Aug-2022 Medical 1 1077592 Hoso hl Sen-ices nntlTi eat r-em MdnitCflng and Management Charges NT-PRO BNPfN-TERMINALPRO BRAIK NATRIURETIC PEPTIDE) - SERUM ANM-ICR-64010 1,381.60 Apollo ■ hospitals IP No: 1076161 -52 7,200.03 -12 8 336.03 Dept Sub Total : 6,336.00 1 7.200.00 -12 6 338.00 Dept Sub Total ; 6,336.00 1 7,200.00 -12 6,336.00 6.336.00 Dept Sub Total : 2127 1 7.200 00 -12 0 336 00 0 23.89 30813 1 23 89 1 20.62 0 20.62 2 77890 1 57200 0 572.00 3 58447 1 5.92 0 5.92 4 33862 30813 1 23.89 0 23.89 5 646.32 Dept Sub Total : 02-Aug-2022 347.00 0 347.00 1 ‘ AH the above dates indicated as Date & Time of the entry only Page 5 of 10 Disclaimer : for enquires, appointments contact: 022 - 3350 3350 04-Aug-2022 Wards Others ROOM RENT(SINGLE) BUDECORT RESPULES 0 5MG'2 ML'HSN: 30049099} DUOLIN 3ML RESPL'LES 5 ’ SiHSN: 3004} AEROMISTfADLL* NEBULIZER}#{HSN:9018) -EVOLIN 0.63MG R ESPL LESIHSN 30049091) 3UDECORT RESPLLES 0.5 MG.'2 ML(HSN 30049095} Dept Sub Total : Dept Total : Dept Sub Total : Dept Total : 1,232.00 1,232.00 6,336.00 25,344.00 11066 Ward Pharmacy(999311) 01 -Aug-2022 32>GS. ’ 2O22 22:40 01. ’ 081'2022 23:09 01.'08.7022 23:39 03>'08 , 2022 22:40 04'03 ‘ 2022 22:40 D1.'O&«2022 22:40 01.'08.7022 22:59 01.'08.7022 22:59 01>'08< ’ 2022 23:39 02.'08.'2022 1:12 Regd. Office: Apollo Hospitals Enterprise Limited, Mp. 19. Bishop Gurdu-.v, Raja Aiinamalali'Ui<-.f , Chennai - 400 028. CIN: L85 ’ 10TN1979PLCD8035 Apollo Hospitals, Pio: #13 Parsik Hill Road. 0*f Jran Road, Sector 23, ORD Bclapur, Novi M.umbai-400 614, Maharashtra, India I T: -91 22 3350 3350 I Fat No.: -9 ’ 22 27533'80 Emergency No. '066 E: infoiaapollohospitats.cOm I mumbai.apollohoscitals.corr For on ne sppoinlment: aw askapollo.com Keep the records carefully and bring them along during your next visit to our Hospital Abollo Bill No : 1.400.00 ANMIP94642 01>O8?2C22 23:05 ANM-ICR-64010 1 232 00 Name : Mrs. KISHORI GAJBHIYE 1 IC6344S LIVER KIDNE V BASIC PROFILE Apollo ■ hospitals ________ IP No ; 1063445 Room Rent(999311) 01 -Aug-2022 Wards Others • 2127 ROOM RENT(S!NGLEj 02-Aug-2022 Wards Others 2127 ROOM RENT(SINGLE) 61203 3 WAY VEIN O LINE -1CCt.'(HSN.9018i 03-Aug-2022 Wards Others 2127 ROOM RENTfSINGLE) IP No : 2 214.03 1 441. CO 0 441.03 3 1714 ’ 3 111.C0 02,'0a. , 2022 2 0 111 00 4 53825 1:12 20.39 02'08/2022 1 20.39 0 5 82059 1:23 02.'08. ’ 2022 3 17.7G 0 17.76 6 33802 2:43 30813 02'08>'2022 2 47.78 0 47.78 7 2:43 1 02> ‘ 08/2022 20.23 0 20.23 8 80202 2:43 02'08/2022 1 5.01 0 5.01 9 80088 7:53 11.99 02/08/2022 1 11.99 0 1C 35047 7:53 5.01 5.01 1 C 1- 80088 129.00 129.03 02'08/2022 1 C 12 51034 9:54 0 30.60 07879 02'08/2022 2 30.60 13 11:48 1 2O5.CO 0 205.00 14 24949 80.00 2 80. CO 0 33319 15 17.76 3 0 17.76 16 33362 3 61.86 0 61.86 17 77890 3 120.CO 0 120.00 02'08/2022 18 333'9 2342 4.52 0 4.52 19 47830 11.99 0 11 99 23 35647 1 5.01 0 5 01 21 37972 02'OS'2022 2 30 60 3 30 60 22 67879 20:42 47 78 47.78 2 0 33813 23 1 20 23 0 20.23 24 06202 Dept Sub Total : 2,005.52 03-Aug-2022 “ All the above dates indicated as Date S Time of the entry only Page 6 of 10 Disclaimer : Fo- enquires, appointments contact 022 - 3350 3350 02'08/2022 1:12 02'08/2022 20:42 02-Cfi. 1 2C22 20:42 02/08'2022 20:42 VENFLCN PRO SAFETY 2CG:HSN 90183930} VEI.FIX IV CANNULAZIATION □RESSI{HSN:48211C1O) POSIFLUSH SP-10ML SY RENGESfHSN: SOI B3220) LEVOUN 0 63MG RESPULES(HSN:3C 349091) EU DECORT RESPULES 0.5 MG/2 ML(I-SN 3004=399) MCNTAIR FX TA9 158.3cos:S (PMIS0140SG247) MET XL 25MG ER TAB 2C'S:HSN:3034) NATRILIX SR - 1 5 MG TAE\HSN:30349079) MET XL 25MG ER TAB 2C ’ S(HSN:3O34) ALEX SYRUP 133ML{HSN: 33049099 J (PMIS01 4096651) DJOLiK LD RESPULES 2 5ML(HSN 30C49C91) KESC_230r»'L LlQfHSN 3004) (PMIS014097OB9) CORT-S 100MG :NJ(HSN 30043233) (PMISD1 4097069) LEVCLIN 0.63MG RESPULES(HSN:30349091) CJOLIN3ML RESPULES 5'S(HSN:3304) CORT-S 100MGI NJ(HSN .30043200) /PMtSOI 4C9B575) STARPRESS-XL25 TABIHSN 30049074} NATR LIX SR - ’ 5 MG TABIHSN 3004CC79} PROLOMET XL25MG TABiHSN 30049079} DUOLIN LD RESPULES 2.5ML(HSN:30349091) MCNTAIR-LCTA3 l5'S:HSN:30049099) BUDECORT RESPULES 0.5 MG* MLiHSN: 30049099) MONTAIR FXTAB t5a.ipo$:S fPMIS014098575) 02'08/2022 11;43 02'08/2022 11:43 02'08/2022 11:48 02'08/2022 23:42 02'08/2022 20:42 02/08/2022 7:53 02/03*022 20:42 (Wrwrnamcv 11066 Bill No: 214.C0 ANMIP94642 02'08/2022 1:12 Regd. Office: Apollo Hospitals Enterprise Limited, No. 1?. Bishop Garden-.., Raja Aiywmaialpuram, Chenr-ai 630 028 CIN l 851 •mM97VP| 008035 Apollo Hospitals, Plot r/'3. Par*, k Hill Roa:, Of* Ura- Road Setter 23, CBD Belapur, Havi Mumba -iCD 614. Maharashtra. India I T .91 22 3350 335-3 I Fax No -91 22 27533080 1 Emergency No.: 106= E: in'oliapotio-osoiials com I mumDai.apollohosBitsls.com For online jpiicmlment v .- aw askacollo.com Keep the records carefully and bring them along during your next visit to our Hospital Apollo Apollo ■HOSPITALS Name : Mr s. KISHORI GAJBHIYE 78511 ANM-ICR-64010 o IP No: 302W 1 18 04 2 87879 2 30.60 0 30.60 77390 3 03.'08'2022 3 61.80 I 61.86 23:36 30813 4 2 47.73 0 47 78 8CS88 1 5.01 0 5.01 6 64102 03/03- ’ 2022 1 49.96 49.96 0 23:36 86202 1 20.23 0 20 23 J 564? 8 03( , 08?2022 1 11 99 0 11.09 23:36 Dept Sub Total : 309.43 04-Aug-2022 76201 O4.'Ca-2022 1 10.96 0 10.06 4 02 2 33862 C4i'08?2022 2 II 84 0 11 84 7 38 34272 3 04/08. ’ 2022 1 399.16 0 399 16 15:13 51552 4 04/08'2022 1 436.59 0 436.59 15:13 5 33862 O4.'C&'2022 2 11.84 0 11.84 20 55 86202 C4'08.'2022 6 1 20.23 0 20.23 20.55 30813 04;38;2022 1 23,89 0 23.89 20:55 47830 8 04,'03>'2022 4.52 1 0 4 52 20:55 a 76201 04/C&-2022 1 10.96 0 -0 96 20 55 10 77890 04.'0872022 2 41 24 0 41 24 20 55 J5647 II 1 11.99 0 11.99 Dept Sub Total : 983.22 05-Aug-2022 59697 05,'082022 7 122.43 0 122.43 11:13 J7972 35 07 2 05.'0a..2022 7 0 35 07 11-10 ‘ All the above dates indicated as Date & Time of the entry only Page 7 of 10 Disclaimer : Tiose C4. ’ 08.'2O22 20:55 O3. ‘ C&-2022 23 36 NATRILIXSR-1.5MG lABlHSN. 30649079) ZEROSTAT VT SPACER •:HSN:90192099) LEVOLIN 0 B3MG RESPULES(HSN:3DC49091 ) MONTAIR FX TAB 15&aD0s;S IPMIS014104925) BJDECORT RFSPULES 0.5 MG/2 Ml.(HSN;30049099) 03.-C& ‘ 2022 23 36 MCNTEMAC FX rAB(HSN:3CO49099) {PMISOHIGGOCtj PROLOMET Xi 25MG TAB(HS *30049079) SIARPR l SS-XL 25 TAB(HSN:30049074) CUOLIN 3ML RESPULES 5'S;HSN:30C41 BUDECOR1 RESPULES O.SMG'2 ML(HSN 30049099) CILACAR M 10/25MG TAB lO'SiHSN 30049074) LEVOLIN 0.63MG RESPUL=S(HSN:30C49091 ) FORACORT 200 MCG INHA LERiHS N :30049C99 ) PANSEC IV 40r. ’ G{HSN: 30049039; fPMlSOi4lO2087) MONIAIR FX 1AB ’ 5'S (PM IS0 14102087) NATRIIIXSR- 1.5 MG TABlHSN 30049079) CILACAR M 1O.'25MG TAB 1OS(HSN 301)49074) DUOLIN 3ML RESPULES 5S(HSN:3O34) METXL25MG LR TAB 20 , S{l

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