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BBMP Employee Health Care Form

Employee ID: {EMPLOYEEID}

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Upload Latest Photo :*
Employee Name :*  
Middle Name :*
Last Name :
Father's Name :
Mother's Name :
Husband's Name :
Date of Birth :*
Gender checked > Male  checked > Female
Blood Group :*
Civil Status :
Residential Address:
Postal Code :*
Mobile Number :
Resident Phone Number :
E-mail Address :
Passport Number :
PAN Card Number :
Proof of Documents for DOB to be Uploaded :
Proof of Identity Documents to be Uploaded :
EID Number for Managed Health :
EID Number According to BBMP :
ICST Code :
Name of the Employee as on the BBMP Records :
Designation :
Group :
Department :
Constituency :
Date of Retirement :
Number of Dependents :
Date of Health Card Issue :
Dependent ID -1 :
Dependent Blood Group -1 :
Dependent Date of Birth -1 :
Dependent ID -2 :
Dependent Blood Group -2 :
Dependent Date of Birth -2 :
Dependent ID -3 :
Dependent Blood Group -3 :
Dependent Date of Birth -3 :
Dependent ID -4 :
Dependent Blood Group -4 :
Dependent Date of Birth -4 :
Dependent ID -5 :
Dependent Blood Group -5 :
Dependent Date of Birth -5 :
Validity From :
Validity To :
Office in which Employed :
Salary :
Place of Duty :
The Place at which the Patient fell Ill :
Nature of Illness :
Nature of Illness Duration (In Days) :
Details of Amounts / Claimed :
Total Amount Claimed :
List of Enclosures Uploaded :
Hospital Ward Type :
Date of Admission to Hospital :
Time of Admission to Hospital (HH:MM:SS) :
Date of Discharge from Hospital :
Time of Discharge from Hospital (HH:MM:SS) :
Disease :
Disease Conditions:
Examinations and Tests done :
Tests done for Disease :
Final Diagnosis :
History of the Present Illness :
Clinical Findings :
Treatment and/or Operative Note :
Laboratory Data :
Duration of the Treatment(In Days) :
Remarks / Post Operative Advice :
Status of the Patient after Hospitalization :
Treated By (Doctors Name) :
Name of the Investigation :
Treatment Procedure :
Rates approved for A-1 Cities :
Total Amount Claimed by the Hospital :
Admisible Amount :
Difference Amount :
Number of Items to be Corrected :
Final Amount Approved :
Amount Approved By :
Status of the Hospital Invoice :
Insurance Number :
Insurance Company :
Insurance Company Phone No-1 :
Insurance Company Phone No-2 :
Insurance Company Cellphone :
Insurance Company Fax Number :
Insurance Company E-mail :
Schemes for Better Health Care :