Consents

At the time of admission: -

I, Mr/Mrs/Miss ________________________________ have read the rules and regulations of Holy Spirit Hospital, and hereby agree to abide by the same.

I am admitting the patient in ____________ class, for which I will pay Rs. ____________ as deposit and agree to pay the balance of Rs. ____________ within 24 hours.

Date: Signature of relative: Signature of patient:

For change of class of bed: -

I, Mr/Mrs/Miss ________________________________ would like to shift from ________ to __________ class w.e.f ________ on my own wish and undertake to pay all the differential charges applicable at the time of final settlement.

Date: Signature of patient:

For Cashless service: -

I, Mr/Mrs/Miss ________________________________ undertake to;

1. Pay Rs.2000 as security deposit at the time of admission/ within 24hrs of admission and understand that this deposit will be refunded only upon receipt of payment for the bill by the hospital.

• Hand over all original documents such as the discharge card, investigation reports over to the hospital at the time of discharge.

3. If hospital expenses exceed the amount authorized by the Insurance Company/TPA, to pay the difference at the time of discharge.

4. Pay for all non-medical expenses such as registration fees, telephone charges, toilet articles, attendant pass charges, medical record fees, administration charges etc. at the time of discharge.

5. To settle the hospital bill if the hospitalization comes under any of the policy exclusions resulting in denial of cashless facility by the Insurance Co./ TPA, at the time of discharge.

Date: Signature of patient: