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TPA / lnsurance Company within 7 days of the patient's discharge. c. We agree that TPA / Insurance Company will not be Iiable to make the payment in the event of any discrepancy between the facts in this form and discharge summary or other documents. d. The patient declaration has been signed by the patient or by his representative in our presence.
Submit the pre-authorization request on the latest form circulated by the TPA. Earlier forms do not contain fields now mandated by the IRDA. Latest Pre-authorisation Request Form. Ensure that all the columns in the pre-authorization request form are duly completed LEGIBLY.
You can conveniently access and download the required claim forms for submission here. List of Claim Documents/Claim Forms. A & B + ECS Form. Reliance Claim Form. Reimbursement Claim Form - Insured Only. Reimbursement Claim Form - Hospital Only. Pre-Authorisation Form Only. Electronic Clearing Services [ECS] Only.
Pre Auth Form. DECLARATION BY THE PATIENT / REPRESENTATIVE. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/T.P.A after the discharge. I agree to sign on the Final Bill & the Discharge Summary, before my discharge.
Fill the Pre - Authorisation Form, available with the Network Hospitals upon showing Vidal Health Card. This can also be obtained from any of the Vidal Health Insurance TPA Pvt. Ltd. branch offices or can be downloaded from this site.
Uniform Pre-authorization Request Form: Please find a copy of the new format (Pre-authorization Request Form) to be used w.e.f. 01.04.2013 in our website under the link “Pre Authorisation Form Only”. You are kindly requested to: . Advise your Insurance Help Desk/ Pre-auth Team to utilize this format with immediate effect.
Customer needs to drop into a Vidal Health Insurance TPA Pvt. Ltd. network hospital to give a copy of his / her Vidal Health Insurance TPA ID card and Identity proof at Hospital reception. Pre-authorisation form has to be filled which has two parts.
