De the original preauthorization request form in lieu of PART A (To be filled in block letters) DETAILS OF HOSPITAL a) Name of the Hospital: b) Hospital ID: c) Type of Hospital: Network Non Network (If non network fill section E) d) Name of the treating doctor: e) Qualification: f) Registration No. with State Code: g) Phone No. DETAILS OF THE PATIENT ADMITTED: a) Name of the Patient: b) IP Registration Number: f) Date of Admission: j) Type of Admission: c) Gender: D D M Emergency.
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