CityCare Multispeciality Hospital
14, Ring Road, New Delhi 110024
Ph: +91-11-4567-8900
Clinical Reg. DL-CE-2019-04412
Rohini ROH-DEL-008812
Cashless Request (Part-C) + Authorisation (Part-D)
No: CL/25-26/03210
Dt: 20-09-2026 10:15
Patient
Geeta Sharma · 48Y / F
UHID: UHID-2024-090112 · IPD: IPD/25-26/03210
Admission: PLANNED · 20-09-2026
Dx: Cholelithiasis — laparoscopic cholecystectomy [DC11.1]
Proposed: Laparoscopic cholecystectomy under GA — planned 4-day stay
Policy / TPA
Star Health · Star Health TPA
Policy: P/123456/01/2025/009812
Member ID: SH-4451209
Claim: CLM-2026-55210
Treating doctor: Dr. V. Kapoor (DMC-41028)
| Chronic history | Since |
|---|---|
| Diabetes | 2019 |
| Hypertension | 2020 |
| Heart disease | — |
| Lipids | — |
| Arthritis | — |
| Asthma/COPD | — |
| Cancer | — |
| HIV | — |
| Expected cost split | Amount |
|---|---|
| Beds + nursing | ₹12,000.00 |
| Professional fees | ₹15,000.00 |
| Investigations | ₹9,500.00 |
| Medicines + consumables + implants | ₹32,000.00 |
| Other (OT + anaesthesia) | ₹7,000.00 |
- Grand Total
- ₹75,500.00
Package total ₹75,500.00. Doctor declaration: admission and estimate clinically justified — Dr. V. Kapoor (DMC-41028).
Authorisation (Part-D)
Status: Authorised (initial) · Auth no. AUTH-2026-88112 · Amount ₹60,000.00
Final claim checklist (cover)
- ☐ Pre-auth letter
- ☐ Signed claim form
- ☐ Discharge summary
- ☐ Main + break-up bills with patient signature
- ☐ OT notes
- ☐ Investigation reports + requisitions
- ☐ Pharmacy bills + indents
- ☐ Implant invoices / stickers
- ☐ ID proof
- ☐ MLC/FIR or death summary (if applicable)
Submit within 2 days of discharge.