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BBMP Emplyee Health Care Form

Employee ID: {EMPLOYEEID}
Employee Name:          
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      1.     checked >    Upload Latest Photo
      2.     checked >    Employee Name
      3.     checked >    Middle Name
      4.     checked >    Last Name
      5.     checked >    Father's Name
      6.     checked >    Mother's Name
      7.     checked >    Husband's Name
      8.     checked >    Date of Birth
      9.     checked >    Sex
     10.    checked >    Blood Group
     11.    checked >    Civil Status
     12.    checked >    Residential Address
     13.    checked >    Postal Code
     14.    checked >    Mobile Number
     15.    checked >    Resident Phone Number
     16.    checked >    E-mail Address
     17.    checked >    Passport Number
     18.    checked >    PAN Card Number
     19.    checked >    Proof of Documents for DOB to be Uploaded
     20.    checked >    Proof of Identity Documents to be Uploaded
     21.    checked >    EID Number for Manged Health
     22.    checked >    EID Number According to BBMP
     23.    checked >    ICST Code
     24.    checked >    Name of the Employee as on the BBMP Records
     25.    checked >    Designation
     26.    checked >    Group
     27.    checked >    Department
     28.    checked >    Constituency
     29.    checked >    Date of Retirement
     30.    checked >    Number of Dependents
     30.    checked >    Dependents
     31.    checked >    Date of Health Card Issue
     32.    checked >    Validity From
     33.    checked >    Validity To
     34.    checked >    Office in which Employed
     35.    checked >    Salary
     36.    checked >    Place of Duty
     37.    checked >    The Place at which the Patient fell Ill
     38.    checked >    Nature of Illness
     39.    checked >    Nature of Illness Duration
     49.    checked >    Details of Amounts / Claimed
     50.    checked >    Total Amount Claimed
     51.    checked >    List of Enclosures Uploaded
     52.    checked >    Hospital Ward Type
     53.    checked >    Date of Admission to Hopital
     54.    checked >    Time of Admission to Hopital (HH:MM:SS)
     55.    checked >    Date of Discharge from Hopital
     56.    checked >    Time of Discharge from Hopital (HH:MM:SS)
     57.    checked >    Disease
     58.    checked >    Disease Conditions
     59.    checked >    Examinations for Disease
     60.    checked >    Tests done for Disease
     61.    checked >    Final Dignosis
     62.    checked >    History of the Present Illness
     63.    checked >    Clinical Findings
     64.    checked >    Treatment and/or Operative Note
     65.    checked >    Laboratory Data
     66.    checked >    Duration of the Treatment(In Days)
     67.    checked >    Remarks / Post Operative Advice
     68.    checked >    Status of the Patient after Hospitalization
     69.    checked >    Treated By (Doctors Name)
     70.    checked >    Name of the Invesigation
     71.    checked >     Treatment Procedure
     72.    checked >    Rates approved for A-1 Cities
     73.    checked >    Total Amount Claimed by the Hospital
     74.    checked >    Admisible Amount
     75.    checked >    Difference Amount
     76.    checked >    Number of Items to be Corrected
     77.    checked >    Final amount Approved
     78.    checked >    Amount Approved By
     79.    checked >    Status of the Hospital Invoice
     80.    checked >    Insurance Number
     81.    checked >    Insurance Company
     82.    checked >    Insurance Company Phone No-1
     83.    checked >    Insurance Company Phone No-2
     84.    checked >    Insurance Company Cellphone
     85.    checked >    Insurance Company Fax Number
     86.    checked >    Insurance Company E-mail
     87.    checked >    Schemes for Better Health Care