Location
—Please choose an option—BanashankariElectronic CityHebbalHennurHRBR LayoutIndiranagarSarjapurWhitefieldKanakapura Road ClinicKannamangala ClinicWind Tunnel RoadSector 43Sector 44ZirakpurAlwarpetSaidapetCoimbatoreGurugramMechanic NagarMohaliKhargharMysuruSector 48KharadiLullanagarkolkata

City
—Please choose an option—BangaloreChandigarhChennaiCoimbatoreGurgaonIndoreMohaliMumbaiMysoreNoidaPuneKolkata

State

Name of the Patient

UHID/ MRN No.

IP/OP No.

Bill Amount

Bill Date

Payment Mode
CashCardNEFTUPI

Transaction Reference No.

MH Receipt No.

Date of Payment

Amount Paid (Rs.)

Paid by: Name

Relation
ParentsSpouseRelative/Friends

Refund Claimed (Rs.)

Mode of Refund
NEFT

Reason for Refund

Mobile Number

Correspondence Address

A/C Holder Name

Bank A/c No.

IFSC Code

Enclosed (Cancelled Cheque, Copy of Receipt, Other Details)

I/We do hereby declare that I am a bonafide claimant for the patient, and all the details stated above are true and correct to the best of my/our knowledge and belief. I understand that the hospital will be discharged from its liability with respect to the above transaction upon processing the refund, and it will not be responsible for a refund to incorrect account details, if any mentioned by me.