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CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED BY THE INSURED The issue of this Form is not to be taken as an admission of liablity DETAILS OF PRIMARY INSURED: a) Policy No.: (To be Filled in block letters) SECTION A SECTION B b) Sl. No/ Certificate no. c) Company ...
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CLAIM FORM - PART B 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. DETAILS OF HOSPITAL.
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CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A. TO BE FILLED IN BY THE INSURED. The issue of this Form is not to be taken as an admission of liability. (To be filled in BLOCK LETTERS) SECTION A - DETAILS OF PRIMARY INSURED. a) Type of claim Hospitalization Pre Hospitalization. Post Hospitalization.
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CLAIM FORM - PART B. (To be filled in BLOCK LETTERS) 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. SECTION A - DETAILS OF HOSPITAL. Name of the Hospital. Hospital ID. Type of Hospital . Network.
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Raksha Health Insurance TPA Pvt. Ltd. ISO 9001:2008 & 27001:2013 Certified Company . 0129-3501420. ... Claim Form(Insured) Claim Form(Hospital) Cashless Request Form;
CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A. TO BE FILLED BY THE INSURED. The issue of this Form is not to be taken as an admission of liablity. DETAILS OF PRIMARY INSURED: Policy No.: Sl. No/ Certificate no. Company/ TPA ID No: Name: Address: U R N A M E.
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Document should be only .pdf and size between 0 MB to 15MB! Upload Claim Documents. I will not use the same hospitalization documents to claim at any other. Insurer/TPA or anywhere else. If declarations are found untrue, entire amount shall be recoverable from me (Insured).
