Fundraiser – Littltonescure

Patient Name

Gender

Age

Birth Weight

Hospitial

Location

Consulting Doctor

Admission Date

Estimated cost informed during admission

Estimated period of Hospitalization informed during admission

Total Bill amount as on today

Amount paid by parents so far

Amount Hospital has waved off so far

Outstanding balance as on today

Other NGO’s/ CMRF/ PMRF helping the patient financially, Specify

Covered under insurance / Arogya Shree:

Estimated cost

Estimated period of Hospitalization:

Amount hospital is willing to Wave off, If LOF itakes up the case:

How much more amount can parents pay

Diagnosis and Case Summary

Treatment Plans

Photograph of the child (Admission)

Parent ID, Address and income Proof

Itemized bill as on today

Links