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BBMP Employee Health Care Form

Employee ID: {EMPLOYEEID}
Employee Name :*   Upload Latest Photo :*
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: Office Address:
Postal Code :* E-mail Address :
Mobile Number : Resident Phone Number :
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 :
Department : Group :
Designation : Constituency :
Date of Joining : Date of Retirement :
Date of Health Card Issue : Number of Dependents :
(Add Rows depends upon the Number of Dependents you mentioned above)
Dependent Name Relation Blood Group Date of Birth
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 :