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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.
Check out the GIPSA Declaration Form for Health Insurance Claims from Network Hospitals details at New India Assurance.
and associated cost of it, which is over and above the GIPSA approved tariff, And if I opt to go for final bill reimbursement with insurance company, respective insurance company will reimburse as per GIPSA approved tariff only, rest of the amount has to be borne by myself or patient only. Name of the attender: Signature:
Declaration regarding Insurance Policy (Strike off the option which is not applicable) (i) Declaration when patient has no insurance policy: •I declare that I do not have any insurance policy.
Created Date: 1/18/2018 4:40:44 PM
This form will solicit information from the insured/ customer about his/her PAN/ Form 60 and Aadhar details as per IRDAI guidelines and insurance details as well as his/ her undertaking thereto. The purpose of this declaration form is a disclosure of PAN/Form 60 and Aadhar details and understanding of policy terms and conditions by the ...
FORM 60 [See third provision to of Rule 114B] Form of Declaration to be filled by a person who does no have either permanent account number of general index Register Number and who makes payment in respect of transaction specified in clauses (c) to (f) of rule 114B of the income Tax Act. 1962. 1.
