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    Medical Attendant S/ Hospital Certificate: (Format AI - Death Claim)

    Uploaded by

    Piyush
    This document is a medical certificate template used for life insurance death claims. It requests information about the deceased patient, including [1] personal details, [2] hospitalization/treatment history, [3] reported illness history, [4] diagnosis details, [5] cause of death, and [6] any previous admissions/treatments. The attending medical professional must provide the requested information, sign and stamp the certificate, and attach copies of relevant medical records.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Attendant S/ Hospital Certificate: (Format AI - Death Claim)

    Uploaded by

    Piyush
    603 views2 pages
    This document is a medical certificate template used for life insurance death claims. It requests information about the deceased patient, including [1] personal details, [2] hospitalization/treatment history, [3] reported illness history, [4] diagnosis details, [5] cause of death, and [6] any previous admissions/treatments. The attending medical professional must provide the requested information, sign and stamp the certificate, and attach copies of relevant medical records.

    Original Title

    Medical_Attendant_Hospital_Certificate (1)

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    This document is a medical certificate template used for life insurance death claims. It requests information about the deceased patient, including [1] personal details, [2] hospitalization/treatment history, [3] reported illness history, [4] diagnosis details, [5] cause of death, and [6] any previous admissions/treatments. The attending medical professional must provide the requested information, sign and stamp the certificate, and attach copies of relevant medical records.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    603 views2 pages

    Medical Attendant S/ Hospital Certificate: (Format AI - Death Claim)

    Uploaded by

    Piyush
    This document is a medical certificate template used for life insurance death claims. It requests information about the deceased patient, including [1] personal details, [2] hospitalization/treatment history, [3] reported illness history, [4] diagnosis details, [5] cause of death, and [6] any previous admissions/treatments. The attending medical professional must provide the requested information, sign and stamp the certificate, and attach copies of relevant medical records.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    MEDICAL ATTENDANT S/ HOSPITAL CERTIFICATE

    (Format AI - Death Claim)

    Policy Number _______________________ Date : _________________

    1. Personal details of the Patient (Life Assured):


    Name
    Date of Birth
    Father s name
    Address and contact
    number

    2. Details of Hospitalization/ Treatment:


    Name, Address &
    Tel. No. of referring
    Doctor
    Was he/ she treated as an In- patient or Out - Patient?
    Date of Admission/
    consultation

    3. History reported at the time of Admission/ Consultation:


    Details of illness/ Symptoms

    Date or Duration or Since when


    Date of Diagnosis
    Name, Address & Tel. No.
    of the Doctor/ Hospital
    who Diagnosed/ Treated
    the Patient
    Habits such as Drinking,
    Smoking (quantity &
    duration)
    History Provided by
    (Patient himself/ family
    member/ other)
    History Recorded by

    4. Details of Diagnosis made by you/ your Hospital:


    Provisional Diagnosis

    Date of Provisional dignosis


    Tests done and results of
    the same for confirming
    the Diagnosis
    Final Diagnosis

    Medical Cert/ Page 1 of 2


    Date of final diagnosis

    Treatment Given

    Duration of the Treatment


    Date of Discharge/ Death

    If discharge, then
    condition at discharge &
    advice given for follow up

    5. Details relating to death of the patient in case he/ she was last seen/ treated by you/ your
    Hospital:
    Primary cause of death

    Secondary cause of death

    Were these causes ascertained by


    examination after death or from the
    symptoms & appearances during life?
    Complaints / Symptoms just before the
    death

    Duration of these symptoms


    Was a Post Mortem recommended? If
    yes, please specify reason for the same
    6. Had the patient been admitted or treated by you or your Hospital earlier? If yes, Please
    provide the following details:
    Date In - Patient / Reason for seeking Treatment given
    From To Out - Patient treatment

    Signed at ______________________ this _____________ day of _______________20 _____.

    Signature & Name of the Medical Attendant / Authorized Signatory:


    _______________________________________________________________________________

    Name of the Hospital : __________________________________________


    Address : _______________________________
    _______________________________
    _______________________________
    Tel no. : _______________________________

    Stamp of the Employer:


    Note: Please attach copy of the records

    Medical Cert/ Page 2 of 2

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