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Declaration when patient has insurance policy: I declare that I have following Insurance Policies. Policy No/TPA card No:_________________________________________. Insurance Company:____________________________________________. 2) Whether patient opted for Eligible Room Category under Policy:
GIPSA PPN NETWORK-DECLARATION BY PATIENT/Patient’s ATTENDERName of the Hospital ...
I declare that I do not have any insurance policy. Declaration when patient has insurance policy: I declare that I have following Insurance Policies. Policy No/TPA card No:_________________________________________. Insurance Company:____________________________________________.
s over and above the agreed tariff for the treatment. Further, if I opt to go for final bill reimbursement with insurance company, respective insurance company will reimburse only as per agreed tariff for the treatment. with the treatment shall be borne by me/ patient onlySign. .... Name of the Patient/Patient’s attendant: Sign.
Policy Declaration Form ; IRDAI - Modification Guidelines on Standardization in Health lnsurance ; GIPSA PPN Network - Declaration Form (National, United, New India and Oriental) Discount circular - IRDAI & NIAC
Title: C:\Users\mansi.sawant\AppData\Local\Temp\PPN NETWORK - DECLARATION FORM.docx Author: mansi.sawant Created Date: 10/3/2017 6:36:57 PM
Pre Authorization Form :-PreAuthorization Form [For Cashless Request] Claim Form :-Reimbursement Claim Form [For Insured] Cashless Claim Form [For Hospital] PPN Declaration Forms :-PPN Declaration Form [For PPN Hospital] Form 60 [For PPN Hospital]
