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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
- CLAIM FORM
The issue of this Form is not to be taken as an admission of...
- CLAIM FORM
a. 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 checklist below will be sent to TPA / Insurance Company within 7 days of the patient’s discharge. c.
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.
Name of TPA/ Insurance Company : Raksha TPA Pvt. Ltd] Toll free phone number . ... We confirm having read understood and agreed to the Declarations on the reverse of ...
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)
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Reimbursement claims may be filed in the case of hospitalization at a non-network hospital or for post-hospitalization and pre-hospitalization expenses. Click here for details of submitting a reimbursement claim. We allow you to submit your reimbursement claim online.
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