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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
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.
O. Contact number, if any: (Please complete declaration of this form) TO BE FILLED BY TREATING DOCTOR/HOSPITAL Surgical Management Intensive care Investigation Management Non-allopathic treatment N I V AB UP 1 8 6 0 5 0 0 8 8 8 8 a) Name of lnsurance company: H EL T I N S R C ... 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 ...
We confirm having read understood and agreed to the Declarations on the reverse of this form a) Name of treating doctor: (PLEASE READ VERY CAREFULLY) Patient / Insured Name & Si ature: Si ature of treatin doctor Hospital Seal (Must include Hospital ID)
Preauthorization form needs to be signed by the patient or his family member.
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 (To be Filled in block letters) DETAILS OF HOSPITAL a) Name of the hospital: a) Hospital ID: c) Name of the treating doctor: e) Qualification:
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.
Raksha Health Insurance TPA Pvt.Ltd. - Leading TPA in india. Cashless Everywhere - Experience seamless hospitalization anytime, anywhere! Now, enjoy the convenience of cashless treatment at any hospital of your choice, regardless of whether it is part of the insurer’s network or not.
request for cashless hospitalisation for health insurance policy part — c (revised) (to be filled in block letters) details of the third party administrator/ insurer/ hospital:
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