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information in the pre-authorisation form will be collected from the patient. 4. WE AGREE THAT TPA / INSURANCE COMPANY WILL NOT BE LIABLE TO MAKE THE PAYMENT IN THE EVENT OF ANY DISCREPANCY BETWEEN THE FACTS IN THIS FORM AND
Cashless Claim Form and Pre-Authorization Request form (Part c) 9: Cashless Declaration From for Network Hospital: 10: Cashless Declaration Form For PPN Hospital: 11: For Hospitals - Cashless Facility Admission Procedure: 12: Standard Discharge Summary as per Health Regulation 2016: 13: ... Safeway Insurance TPA Pvt. Ltd; CIN No : U67200DL2004PTC129929 | IRDA Registration No: 26 Valid Upto July 2026.
SAFEWAY INSURANCE TPA PRIVATE LIMITED (IRDA LICENCE No .026) 1800-102-5671 c. 022-66466797 Cashless Request Email ID : info@safewaytpa.in TO BE FILLED BY INUSRED/PATIENT. REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY.
Emergency Admissions: For emergencies, submit the Cashless Facility Request using our Pre-auth Form within 48 hours of admission. Email us at info@safewaytpa.in if you require assistance.
REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICAL INSURANCE POLICY. DETAILS OF THIRD PARTY ADMINISTRATOR. (To be Filled in block letters)
IRDA - Pre-Authorization Form.pdf. 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 (To be Filled in block letters) 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.
In case of a planned hospitalization, client needs to inform Safeway two to three days in advance by faxing us the pre-authorization form (form on Website) signed by the treating doctor.
All non medical expenses, OR expenses not relevant to hospitalization or illness, OR expenses disallowed in the Authorization Letter of the TPA / Insurance Co. OR arising out of incorrect information in the pre-authorisation form will be collected from the patient.
Welcome to Safeway Insurance TPA Pvt. Ltd. We have been licensed by I.R.D.A. As TPA in July 2005, and have setup our head office in New Delhi. We are fully equipped with I.T infrastructure like Server, Computers, Printers and a State of the Art Software.
DECLARATION BY THE PATIENT / REPRESENTATIVE. t all original. documents pertaining to hospitalization to the Insurer/T.P.A afterthe discharg. . I agree to sign on the Final Bill & the Discharge Summary, before my d. scharge.Payment to hospital is govemed by. the terms and conditions ofthe policy. In case the lnsurer / TPA is not liable tosettle ...
