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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/ TPA ID No: e) Address: DETAILS OF INSURANCE HISTORY: a) Currently covered by any other Mediclaim / Health Insurance: b) Date of commencement of first ...
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.
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.
Main Claim -. (Hospitalization Claim) This is reimbursements of your medical expenses incurred during hospital. admission. The admission should be for a planned medical treatment or a medical emergency. Pre Post -. Expenses incurred for tests & diagnostics leading to treatment before 30 days and after 60 days of.
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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)
1 c Claim form duly signed 2 c Original pre authorization request 3 c Copy of pre - authorization approval letter 4 c Copy of photo ID card of patient verified by hospital 5 c Hospital discharge summary 6 c Operation theatre notes 7 c Hospital main bill 8 c Hospital break up bill SECTION D - CLAIM DOCUMENTS SUBMITTED - CHECK LIST ... (TPA B Part)(30_07_20).cdr Author:
authorize TPA / insurance company. to seek necessary medical information / documents from any hospital / Medical practitioner who has attended the person against whom this claim is made. hereby declare that I have included all the receipts for the purpose of this claim & that I will not be making any supplementary claim except
CLAIM FORM FOR HEALTH INSURANCE POLICIES PART revised C (TPA Part C)30_07_20.cdr Author: Geeta Shahu/RGI/Consultant/mtkg Created Date: 8/5/2020 4:00:43 PM
5. 6. D. D. M. M. Y Y. Y Y. Claim form duly signed Copy of the claim intimation, if any Hospital Main Bill Hospital Break-up Bill Hospital Bill Payment Receipt Hospital Discharge Summary Pharmacy Bill Operation Theater Notes ECG Doctor’s request for investigation Investigation Reports (Including CT / MRI / USG / HPE) Doctor’s Prescriptions ...
