CASHLESS AUTHORIZATION REQUEST NOTE
Part A - To be filled in by the Insured
Part B - To be filled in by the Treating Doctor
Policy No. Card No.
Corporate Name Patient Name
Employee’s name Age
Employee ID Sex M F
Mobile No. of Insured Telephone No. of
Insured (with STD Code)
Address of the Insured
¨ ¨
Hospital Name & Add
(Including City, State, Pin code)
Telephone No.
Treating Doctor's Name
Doctor's Qualification Mobile No.
Presenting Complaints
Clinical Findings Past History
Provisional Diagnosis Treatment Plan : Medical / Surgical
Investigations Findings
Particulars Details Particulars Yes/No Since When
Expected Date of Admission Hypertension
Expected Length of Stay (In days) Diabetes
Class of accommodation Coronary Heart Disease
Room Rent + Nursing Charges Any other Heart Ailment
Investigation Charges Paralysis / Stroke
Medicine Charges Cancer
Surgeon / Asst Surgeon Charges Arthritis
Anesthesia + OT Charges STD / HIV
Doctor Visit Charges Alcohol / Drug abuse/ Intoxication
Cost of Implants ( with Name) MaternityInformation
Package Rate (If Any) AccidentInformationInformation
Total Expected Cost of Hospitalization Other (If Any)
InformationMaternity / Obstetric History Menstrual History G P A L LMP EDD
InformationInformationAccident Details Incident History MLC/FIR Done MLC/FIR No.
Yes / No Location
(with STD Code)
Signature of Insured : _________________________________
Signature & Stamp of Treating Doctor ______________________ Rubber Stamp of Hospital & Signature _____________________
090094MI
Mailing Address : ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032
Toll Free Number : 1800 2666 • Toll Free Fax Number : 1800-209-8880 • Fax Number : 040 - 66989160 / 61
Email us : ihealthcare [at] icicilombard [dot] com • Website : www.icicilombard.com
Insurance is the subject matter of the solicitation. IRDA Reg. No. 115.
Fax No.
(with STD Code)

If yes details below
If yes details below
Consent by Patient / Insured : I hereby authorize ICICI Lombard to pay or reimburse the medical expenses as per the policy terms and conditions. This
authorization shall become null and void in the event of :
• incorrect and/ or misleading information regarding the duration of ailments and/ or information regarding the health status
• any discrepancy between the facts presented at the time of hospitalization and at the time of final documents submission.
In such scenario (s) I shall be liable to pay for the hospitalization and related expenditure. I have no objection to ICICI Lombard obtaining or collecting
details of my treatment. I acknowledge and agree that information provided by me/ us are true to the best of my/ our knowledge.
ICICI Lombard Health Care