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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.
j) Currently do you have any other medical claim/health Insurance: k) Do you have a family physician, if yes: Name: k.1) Contact no.: b) Contact no.: f.1) ICD 10 code: i.1) ICD 10 PCS code: h.1) Route of drug administration: a) Name of the treating doctor: c) Name of Illness/disease with presenting complaints: j) If other treatments provide ...
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Date of Discharge. Diagnosis / Nature of disease / illness contracted / injury suffered. 11. Date of injury sustained or disease / illness first detected. 12. Details of the Hospital / Nursing Home in which treatment was taken : Name of the Hospital / Nursing Home. Address of the Hospital / Nursing Home. City.
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 Others.
Login to t.medibuddy.in and select Claims >> Hospitalisation >> Reimbursement. Select the proper beneficiary and ensure you fill the required details. Scan and upload your documents for faster processing of your claim.
Track your claim in real-time using MediBuddy Online or Mobile. Medi Assist sends the approval to the hospital. Further enhancement approvals may be issued on request, subject to terms and conditions of the policy.
Sep 8, 2021 · Download Template. MediBuddy. A claim gets rejected if there are missing documents or if the submitted paperwork lacks necessary details. Check out the list of documents needed here.
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Claims. Submit your hospitalization and domiciliary claims on line and track your claim status in real-time. Track claims Submit claim. Welcome to MediBuddy, your personalized e-gateway to Medi Assist services.
