Covid costs claim format

Claim Format by the requisitioned Private Hospitals, functioning as COVID Hospitals 2020

 

1.

Name of the COVID Hospital

:

 

2.

Address of the Hospital

:

District: PIN:

3.

Contact of the Hospital

:

Land/Mobile : Email ID:

4.

Date of requisition as COVID Hospital

:

 

5.

Date when the hospital is fully handed over to the Requisitioning authority

:

6.

Number of Isolation/ COVID beds notified on the date of Requisition

:

Isolation beds: COVID beds:

7.

Number of Isolation/ COVID beds with Ventilator Support

:

Ventilator support for Isolation beds: Ventilator support for COVID beds:

8.

Number of functional Isolation/ COVID beds at present

:

Functional Isolation beds: Functional COVID beds:

9.

Date of derequisition

:

 

10

. Number of days for which compensation are being claimed

:

11

. Total number of patient admitted for treatment/Isolation so far

:

Dated:

12

. Total treatment cost claimed

:

Rs.

(please provide patient wise break up as given in the Annexure A)

13

. Mobilization Advance received till date (if any

:

Rs.

14

. Net Claim to be reimbursed

:

Rs.

15

. Human Resource

:

Fully / Partially

Annexure-B

16

. List of equipment/medicines etc supplied by Government (if any)

:

Yes/ No

(Attach as Annexure-C)

17

. Infrastructure development (if any ) undertaken by the Government for setting up of exclusive COVID hospital

:

Yes/ No

Page 1 of 1

Date: Place :

Countersigned by:

Date:

Signature of the Owner/authorized Person

_______________________ Hospital

Chief Medical officer of Health/ Deputy Chief Medical officer of Health as authorized

________________ Health District

Declaration by the Private Hospital Authority:

This is to certify that:-

1. We have provided full/partial operational Human Resources (Doctors/ Nurses/ Paramedics/ Security etc.) from the date of requisition or thereafter to run as COVID hospital.

2. All moveable instruments/equipment provided to our hospital for the benefit of treatment shall be the property of the Government and shall be returned back to the Government.

3. I/we do not have any other claim from the Government of West Bengal for the above requisitioned period.

All the information provided above are true and that we will abide by the decision of the Health & Family Welfare Department regarding claim settlement.

* in case of requisitioned Hospital under Kolkata Municipal Corporation the above will be certified by DDHS(Admin)

Page 2 of 2

Annexure-A

Details of treatment Cost incurred for each patient admitted in the COVID Hospital ________________________________________of __________________ District

Sl.

Name of the Patient

Date of Admission

Date of Discharge

Total Days admitted in number

Details Cost break up :

1

         

         

         

a) No. of days admitted: ……….. days @Rs. …… / day

Bed Charges Rs………………….

b) No. of days kept in ventilator: ……. days @Rs. …… / day

 

Ventilator Charges Rs……………………

 

c) Consultation Fees Rs……………………

 

d) Diagnostic cost: Rs……………………

e) Medicine cost: Rs……………………

f)Transpiration cost (if any) Rs…………………….

g) Other Charges (if any) Rs…………………….

 

Total Claim: (a) to( g) Rs……………………

 

2

     

        

     

a) No. of days admitted: ……….. days @Rs. …… / day

 

Bed Charges Rs………………….

 

b) No. of days kept in ventilator: ……. days @Rs. …… / day

 

Ventilator Charges Rs……………………

 

c) Consultation Fees Rs……………………

d) Diagnostic cost: Rs……………………

e) Medicine cost: Rs……………………

 

f)Transpiration cost (if any) Rs…………………….

 

g) Other Charges (if any) Rs…………………….

Total Claim: (a) to( g) Rs……………………

Page 3 of 3

Estimated Cost for Treatment COVID-19 patient in empanelled hospital under West Bengal Health Scheme

Sl No

Name of Cost Components

Treatment in Intensive Care Unit (Per Day)

Treatment In Isolation Bed (Per Day)

For First Day

1

Bed / Room / Accommodation Rent

2400

1800

2

Ventilator Charges

1000

1000

3

C/B PAP Charges

500

500

4

Consultation Fees (4 Nos. consultation is maximum)

1000

1000

5

*Investigation

10000

10000

6

**Medicine

4000

4000

7

ConConsumables excluding PPE and disinfectants of room

3000

3000

8

Special Nursing (two shift)

300

300

Total

22200

21600

Others Day (Maximum 13 days)

1

Bed / Room / Accommodation Rent

2400

1800

2

Ventilator Charges

1000

1000

3

C/B PAP Charges

500

500

4

Consultation Fees (4 Nos. consultation is maximum)

1000

1000

5

*Investigation (including CT Chest)

3000

3000

6

**Medicine

4000

4000

7

ConConsumables excluding PPE and disinfectants of room

2000

2000

8

Special Nursing (two shift)

300

300

Total

14200

13600

Note 1: * It may vary due to other co-morbidities of the patients Note 2: ** It may vary due to other co-morbidities of the patients

Additional Cost can’t be estimated is given below

Name of Cost Components

Investigation cost of NICED

Ambulance Charges of to and fro

Cost of PPE and disinfectants of room

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