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Referral Letter: Employees State Insurance Corporation

This document is a referral letter from an ESIS dispensary referring a 58-year-old male patient named Balindra Paswan for radiotherapy treatment at Mittal Bhilai hospital. The patient has been diagnosed with malignant neoplasm of the gallbladder and the specialist advised 30 sessions of IGRT radiotherapy tentatively starting on February 7th, 2022. The referring doctor is Dr. Roshni Mishra, IMO Grade-II.

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59 views1 page

Referral Letter: Employees State Insurance Corporation

This document is a referral letter from an ESIS dispensary referring a 58-year-old male patient named Balindra Paswan for radiotherapy treatment at Mittal Bhilai hospital. The patient has been diagnosed with malignant neoplasm of the gallbladder and the specialist advised 30 sessions of IGRT radiotherapy tentatively starting on February 7th, 2022. The referring doctor is Dr. Roshni Mishra, IMO Grade-II.

Uploaded by

afakraipur
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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(Form P-1) Employees State Insurance Corporation

Nandini Road, CT (ESIS Disp.)

Referral Letter
DO NOT MUTILATE THE QR CODE

Referral No : Chhat2022000540 Insurance No/Staff/ Pensioner Card : 5915327141


Name of the Patient : Mr. BALINDRA PASWAN Age/Gender : 58 Years /Male UHID : CBHI.0000005393
Address/Contact No :
Affix 3.5 x 4.5
Identification marks (if any) :
Photograph of
IP/Beneficiary/Staff : IP Patient
Relationship with IP/Staff : Self
Entitled for Specialty Rx : YES
Entitled Super Specialty Rx : YES
Diagnosis : ICD - Malignant neoplasm of gallbladder - C23 Remarks :
CGHS (Name and Code)* : 1264 - IGRT(Image guided radiotherapy) - Nuclear Medicine / Radiotherapy Procedures /
Treatment - No Of Sessions Allowed - 30 - Validity Upto - 31/March/2022
Remarks Additional Clinical Information/Procedure/Investigation

Reasons / Purpose for Referral Investigations/Rx/Procedure : K/c Rt Temporal GBM CA specialist advised for IGRT
Radiotherapy tentatively on 07.02.22 for 30 frac

Name of the empanelled hospital whereto refer Hospital Mittal Bhilai hospital
Department Oncology

Name and Designation of the Referring Doctor


Date & Time of Referral : 09-Feb-2022 01:43:59 PM
Dr. ROSHNI MISHRA - IMO Grade-II

Or,Agreeing to / contradicting the above, I voluntarily choose _____________________________ Hospital for treatment of self or
for my _______________________________ (relationship).

Date and Time:_________________


Signature/Thumb Impression of IP/Beneficiary/Staff

Referred to _____________________________Department of__________________________________Hospital/Diagnostic

Centre for______________________________( Reason/purpose for referral).

(VERIFIED & RECOMMENDED BY) (AUTHORISED SIGNATORY WITH STAMP)


(Signature, Name &Designation) (Signature, Name &Designation)
Date & Time: Date & Time:

N.B.
The entitlement eligibility of the patient should also be verified through IP Portal at www.esic.in. Referral shall be
governed by the rules and administrative instructions issued from time to time.Referred Hospital is instructed to perform
only those procedure/treatment for which the patient has been referred to. In case any additional procedure /
treatment /investigation is essentially required to be carried out, permission for the same is mandatorily required from
the approving authority of the referring hospital. The validity of this referral is upto 7 days from the date of issuance or
as per the contract whichever is later and is subject to fulfilment of other terms and conditions as defined in the
contract/agreement.

Printed By : roshmish 2/9/2022

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