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Corporate Office Phone-0129-4289999 (10 Lines),Fax-0129-4289988, All India Toll Free No.18001801444,1800220456,Email at info@rakshatpa.com,website www.rakshatpa.com. Hospital Network: The Service Providers Network of Raksha Health Insurance TPA Pvt.Ltd. is spread allover india More. Cashless:
Raksha New Pre-Authorization Form - Free download as PDF File (.pdf), Text File (.txt) or read online for free. This document is a request for cashless hospitalization for a medical insurance policy. It provides details about the patient, including name, age, policy information. It describes the medical condition including diagnosis, treatment ...
6. Original Claim Form B duly Signed 7. PPN Declaration letter form duly signed 8. Pre-Auth Form Part –C & D in Original. The Hospital is requested to submit the claim within 7 days from the date of discharge or else it will be deemed as this Authorization Letter has not been used & company holds no responsibility for payments
Raksha Health Insurance TPA Pvt. Ltd. ISO 9001:2015 & 27001:2013 Certified Company
c) Pre - authorization obtained Yes No v. FIR No vi. If not reported to police , give reason S.No Documents 1 c Claim form duly signed 2 c Original pre authorization request 3 c Copy of pre - authorization approval letter
c) Pre-authorization obtained d) Pre-authorization Number e) If authorization by network hospital not obtained, give reason f) Hospitalization due to injury Cause If injury due to substance abuse/alcohol consumption test conducted to establish this Medico Legal Reported to Police FIR No. If not reported to police, give reason
TPA / lnsurance Company within 7 days of the patient's discharge. c. We agree that TPA / Insurance Company will not be Iiable to make the payment in the event of any discrepancy between the facts in this form and discharge summary or other documents. d. The patient declaration has been signed by the patient or by his representative in our presence.
