East West Assist Pvt. Ltd. Process Sheet
All claims on card No. :

CCN		Authorized Amount (INR.)
Name		Hospital
Hospital Address
PPN / Non PPN		Network Status
Claim Type	( )	Bed Capacity
Corporate		Current Status
Diagnosis	viral Fever,
Policy No.		Disease Code	B33,
Procedure		CPT Code
Policy Type		Inception Date
Card No.		Line Of Treatment
Status		Date Of Admission
Intimation Date		Date Of Discharge
Sum Insured	Rs.	Balance	Rs.
Doctor's Opinion		Recommend Date
Policy Date	To	Refer Date

	Claim Amount (INR.)	Authorized Amount (INR.)	Deduction	Remarks
Room Rent			0
ICU			0
Dr./Surgeon's Fee			0
Lab Investigation			0
Radiology			0
Other Investigation			0
Ot/Labour Room			0
Procedure			0
Special Procedure			0
Pharmacy			0
Blood Bank			0
Oxygen			0
Implant			0
Consumable		0
Misc			0
Non-Gipsa Package			0
Gipsa Package			0
Domiciliary			0
Sub-Total	0		0
Discount		-
Other Discount	0 %	-
Copay	0	-
Other Deduction	0	-	-
Service Tax	0 %
Total			0
GST	0%	-
TDS	0%	-
Net Amt. Paid		0
Remarks for Deduction

Do Claim No.	Imode Date	Cheque Amount	UTR No.	Date	In Favour Of

Doctor Name	First Authorizer Signatory	Second Authorizer Signatory