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ICICI Lombard Health Care. CASHLESS AUTHORIZATION REQUEST NOTE. Toll Free Number: 1800 2666 • Fax Number: 1800 209 8880 / 040 6698 9160 / 61 • Email us: cashlessrequest@icicilombard.com. TO BE FILLED BY THE INSURED / PATIENT. Name of Patient: Gender: Male Female 3) Age: Years 4) Date of Birth: D. M. Y. 5) Mobile No.:
form and discharge summary or other documents. d. The patient declaration has been signed by the patient or by his representative in our presence. e. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications. f.
Claim documents to be dispatched to: ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad, TS-500032. Your Claim details are just an SMS away, Please SMS <KEYWORD> to 57 57 58. imS.
Download ICICI Lombard Pre Authorization Form . ICICI LOMBARD will not be held liable for the payment to the event of any discrepancy between the facts presented at the time of admission & in final documents submission.
Step 3: The customer needs to fill out the pre-authorization form and submit it to the hospital. The pre-authorization form is then sent for approval to ICICI Lombard Health Insurance Company. Once the form is approved, the customer can avail of the medical treatment.
Health Care Claims Corner - ICICI Lombard General Insurance Company provides Health Care Claims Corner for all covers and Policies.
