CHECKLIST FOR LAUNCHING OPD HEALTH INSURANCE CLAIM

Financial Year 2019-20

(Kindly attach this checklist at top of photocopy set of claim)

Attached at
Sr. # Description Page No. Remarks
1,2,3….
1 Properly filled & signed OPD Health Claim Form 1
2 Copy of health card 2
Copy of Doctor’s prescription (on Dr/Hospital letter
3 head with valid address & contact#), with date,
signed and stamped (fresh)
Doctor’s consultancy charges invoice(s) with date,
4
signed and stamped (original)
Medicine invoice(s) with date, signed and
5 stamped (with valid address & contact# of
pharmacy) (original)
6 Copy of Test(s) Report(s) if any
Test(s) Report(s) charges invoice(s) with date, signed
7
and stamped (original)

For repeat medicine (only in case of prescribed by the

8 doctor on prescription), please
attach copy of doctor’s prescription and
purchase medicine for the period prescribed

I hereby declare that the claim is prepared as per the above-mentioned checklist and amount
Rs._________________ (Rupees________________________________________________________)

stated in the attached claim is correct and was spent on medical expenses of undersigned/
dependent(s). Further, if any statement(s)/document(s) proved false, it will make the undersigned
liable for strict disciplinary action as deemed appropriate by the Competent Authority.

Name of Employee: _ Designation:

Department: _ Employee No.

Signature of Employee: Date: