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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
a. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization. b. All valid original documents duly countersigned by the insured/patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient’s discharge. c.
Name of TPA/ Insurance Company : Raksha TPA Pvt. Ltd] Toll free phone number . ... We confirm having read understood and agreed to the Declarations on the reverse of ...
List of Documents to be carry with the pre-authorization Form 1) Fully Filled pre-authorization form (provided by the hospital). 2) Pan card & Adhaar card of the Patient.
The issue of this Form is not to be taken as an admission of liability Please include the original preauthorization request form in lieu of PART A (To be Filled in block letters)
Preauthorization form needs to be signed by the patient or his family member.
CLAIM FORM - PART B. DETAILS OF HOSPITAL. TO BE FILLED IN BY THE HOSPITAL The issue of this Form is not to be taken as an admission of liability Please include the original preauthorization request form in lieu of PART A.
