HEALTH CENTRE
INDIAN INSTITUTE OF SCIENCE
BANGALORE 560 012
U N D E R T A K I N G
(Undertaking to be furnished by Employee/Pensioner/Family Pensioner before hospitalization for self/dependants)
1. I have been informed about ward eligibilities and other charges.
2. I have been given to understand that non-medical expenses are to be borne by me.
3. I have been informed that the insurance company will take a minimum of 4 hours to authorize the medical expenses to hospital on receipt of final bill from the hospital.
4. I have been informed that any amount spent over and above the insurance coverage, will be reimbursable, if any, after regulating the entire hospitalization bill as per St. John’s Hospital rate and as per Institute norms.
Signature
(Employee/Pensioner/Family Pensioner)
OR their dependent
Name of the Employee/Pensioner
/ Family Pensioner :
Department :
Employee No./Pensioner No. :
Date :
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