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GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital) DATA ELEMENT DESCRIPTION FORMAT a) Name of the hospital: b) Hospital ID c) Type of Hospital c) Name of treating doctor SECTION A - DETAILS OF HOSPITAL e) Qualification f) Registration No. with State Code g) Phone No. Enter the name of hospital
CLAIM FORM - PART B. TO BE FILLED IN BY THE HOSPITAL. We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited. Date: M. M.
Address. Enter the full postal address. Include Street, City and Pin Code. b) Phone No. Enter the phone number of hospital. Include STD code with telephone number. c) Registration No. with State Code. Enter the registration number of the doctor along with the state code.
Claim Form - Part B. To Be Filled In By e 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. Name of the hospital: Hospital ID: Type of Hospital: Network.
CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL. The issuance of this Form is not to be taken as an admission of liability Please include the original pre-authorisation request form in lieu of PART A. 1800 266 3202.
CLAIM FORM - PART B. (To be filled in BLOCK LETTERS) 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. SECTION A - DETAILS OF HOSPITAL. Name of the Hospital. Hospital ID. Type of Hospital . Network.
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. Name of Hospital : Hospital ID : Type of Hospital : Name of the treating doctor : Qualification :
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 form in lieu of PART A DETAILS OF HOSPITAL DETAILS THE PATIENT ADMITTED.
Kotak Health Care - claim form part B. General Insurance. Kotak Group Smart Cash Claim Form - Part B. TO BE FILLED BY THE HOSPITAL. The issue of this Form is not to be taken as an admission of liability Please include the original pre authorization request form in lieu of PART A (To be filled in block letters) DETAILS OF HOSPITAL.
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) A DETAILS OF HOSPITAL-a) Name of the hospital: b) Hospital ID: c) Type of Hospital: Network Non Network (lf non network fll section E) Disclaimer: SBI General Insurance Company Limited I Corporate & Registered Office: ‘Natraj’, 301, Junction of Western Express ...
