BEEASSIST HEALTH INSURANCE
REIMBURSEMENT CLAIM FORM

Policy Number: POL-1001
Member ID: M-1001-02
Patient Name: Karthik Nair
Date of Birth: 02/11/1982
Claim Type: Inpatient
Hospital Name: CityCare Multispeciality Hospital
Provider ID: PRV-201
Date of Admission: 02/09/2026
Date of Discharge: 05/09/2026
Diagnosis: Acute appendicitis
ICD-10 Code: K35.80
Total Amount Claimed: Rs. 68,400.00
Date of Submission: 14/09/2026

Declaration: I confirm that the information above is true and complete.
Signature: Karthik Nair
