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Is your child in need of medical aid? Heal-a-Child assists certain cases and covers the cost of surgery either fully or partly depending on the case. Fill out the form below to apply for aid.

Application of HAC Support

Case Information

Patient Name:

Gender:

Age:

Birth Weight:

Hospital:

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:

Parents Information

Father Name

Father Contact Number

Father Occupation

Father Monthly Income

Required documents for Evaluating the Case:

Diagnosis and Case Summary

Treatment Plans

Photograph of the child (Admission)

Parent ID, Address and income Proof

Itemized bill as on today

Patient Name:
Parent Email id:
Age:
Hospital:
Consulting Doctor:

Parent Contact Number:
Gender:
Birth Weight:
Location Area:
Admission Date:

Estimated cost informed during admission:
Estimated period of Hospitalization informed during admission:

Total Bill amount as on today:
Amount Hospital has waved off so far:

Amount paid by parents so far:
Outstanding balance as on today:

Other NGO’s/ CMRF/ PMRF helping the patient financially, Specify:
Covered under insurance / Arogya Shree:

For further Treatment

Estimated cost:

Estimated period of Hospitalization:

Amount hospital is willing to Wave off, if HAC takes up the case:
How much more amount can parents pay:

Required documents for Evaluating the Case:

Diagnosis and Case Summary

Treatment Plans

Photograph of the child (Admission)

Parent ID, Address and income Proof

Itemized bill as on today

Patient Name:
Parent Email id:
Parent Contact Number:
Age:
Hospital:
Consulting Doctor:

Gender:
Birth Weight:
Location Area:
Admission Date:

Estimated cost informed during admission:
Estimated period of Hospitalization informed during admission:

Total Bill amount as on today:
Amount Hospital has waved off so far:

Amount paid by parents so far:
Outstanding balance as on today:

Other NGO’s/ CMRF/ PMRF helping the patient financially, Specify:
Covered under insurance / Arogya Shree:

For further Treatment

Estimated cost:

Estimated period of Hospitalization:

Amount hospital is willing to Wave off, if HAC takes up the case:
How much more amount can parents pay:

Required documents for Evaluating the Case:

Diagnosis and Case Summary

Treatment Plans

Photograph of the child (Admission)

Parent ID, Address and income Proof

Itemized bill as on today