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Maharashtra Police Preauth From

This document contains an initial intimation letter that hospitals in Maharashtra are to send to the Maharashtra Health Services (MAHS) regarding patients covered under the Maharashtra Police Kutumb Arogya Yojna (MPKAY) health insurance scheme. The letter includes fields for the hospital to provide information about the patient, their relationship to the insured police employee, basic medical details, estimated costs and duration of care. It also includes fields for the patient or accompanying family member to provide identification and employment details of the insured police officer. The letter is to be signed and stamped by an authorized hospital representative.

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M/s Microtech
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2K views1 page

Maharashtra Police Preauth From

This document contains an initial intimation letter that hospitals in Maharashtra are to send to the Maharashtra Health Services (MAHS) regarding patients covered under the Maharashtra Police Kutumb Arogya Yojna (MPKAY) health insurance scheme. The letter includes fields for the hospital to provide information about the patient, their relationship to the insured police employee, basic medical details, estimated costs and duration of care. It also includes fields for the patient or accompanying family member to provide identification and employment details of the insured police officer. The letter is to be signed and stamped by an authorized hospital representative.

Uploaded by

M/s Microtech
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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MAHARASHTRA POLICY KUTUMB AROGYA YOJNA

Maharashtra Police: Desk No 28, Maharshtra Rajya Police


Mukhyalaya, S B Singh Marg, Colaba, Mumbai 400039

Initial Intimation Letter to be forwarded by Hospital to MAHS


Information to be filled in by the Member :

Name of Patient: Shri / Smt / Kumar / Kumari : Name of Employee : Shri / Smt.

Patient's UHID No.: MAHP Employee's UHID No.: MAHP


Age : Sex : Male / Female Basic Salary: Rs. Buckle No.:
Relation with Employee : Wife Working : Y/N Designation :
Apart from MPKAY Scheme Claiming from Place fo Working with Address :
any Insurance / Compay / Govt : Yes / No
If YES Name of Company : Personal / Residential Contact No. :
No. of Children :
Residential Address :

Information to be filled in by Treating Doctor / Hospital :

Name of the Hospital :


Date of Admission : Admission Under Dr.
Presenting Complaing :

History of Presenting Complaints :

Past History : HTN : DM : Others :

Clinical Findings :

Provisional / Differential Diagnosis :


Proposed line of Treatment :

In Case of RTA, please mention if the patient was under infulence of Alcohol / Drug and
send Attested MLC and FIR copy along with the Intimation letter

Approximate Duration of Stay : Approximate Expenses :


Class of Accommodation :
Treating Doctor's Name : Specialty : Registration No. :

Authorized Signatory :

Name & Designation :

Seal of the Hospital :

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