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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 (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:
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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.
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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.
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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 ...
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Get Your Claim Details with Member-ID Claim Number Employee Number Policy Number.
the insured is taken on this form after Claim Form B is fully filled up by us. Hospital have required infrastructure to fulfill the hospital definition as per IRDA guideline, which is reproduced below:
People also ask
How to fill Raksha TPA claim form?
What is the procedure for hospitalization in Raksha TPA (P) Ltd?
When to submit bills in original form to Raksha TPA?
What are the documents to be submitted to Raksha TPA?
Pre - Post. 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.
