

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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