Search Read free for 30 days

 100% (2) · 3K views · 2 pages

Sail Ipd Form
Uploaded by shami

Mediclaim reimbursement form Full description

     
Save 100% 0% Embed Share Print

Download now 1 of 2  Search document 

ANNEXURE- A: CLAIM FORM - IPD

CLAIM FORM
(Issuance of this form does not amount to admission of any liability under the claim on the part of the insurance.)  

1. Name of the Patient (In Capitals):

2. MIN No.

3. Detail of the person undergoing treatment: 

(a) Name of Patient & relationship to the insured: 
(b) Date of Birth: (c)Phone No.:
(d)Mobile No.: (e) E-Mail – I.D.
(f) Residential address:

4. Nature of Disease/illness contracted or injury suffered:

5. Date of injury sustained or Disease/ illness first detected
6. (a) Name of the Hospital/ Nursing Home/Clinic:
(b) Address of the Hospital/ Nursing Home/Clinic:
State/ Union Territory
(c) Registration no:
(b) Date of Admission: (c) Date of Discharge:

7. Total Amount Claimed: Rs.

I have incurred on the treatment of disease/illness/accident referred to above the expenses as per the details given by me
in the Schedule of Expenses given overleaf. In support of the above claim, I enclose the following documents:

Claim Form Duly Signed: Yes/No Pre Hospitalization bills ___ Nos. Yes/No
MDI Pre-Authorization Certificate: Yes/No Post Hospitalization bills ___ Nos. Yes/No
Claim Intimation Letter Yes/No Hospital Payment receipt Yes/No
Discharge Summary Yes/No Hospitalization Bill Yes/No
Medicines Bills with Dr’s prescription Yes/No Surgeon’s surgery certificate Yes/No
Operation Theater / Pharmacy Bills Yes/No Surgeon/Consultant’s bills Yes/No
Investigation reports with Dr’s prescription Yes/No
MRI ___ Nos. Yes/No ECG ___Nos. Yes/No
CT scan ___ Nos. Yes/No X-Ray ___Nos. Yes/No
US scan ___ Nos. Yes/No Other’s (If any) Yes/No
I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or shall make any
false or untrue statement, suppression or concealment, my right to claim reimbursement of the said expenses shall be
absolutely forfeited. I further declare that, in respect of the above treatment, no benefits are admissible under any other
Medical Scheme or Insurance.

21

Free Parenting E-book Download

Free Parenting E-book Bournvita
 

SCHEDULE OF EXPENSES INCURRED BY

THE CLAIMANT
(Attach separate Annexure for details of bills)
Details of expenses claimed under
Hospitalisation Amount Claimed 
(To be supported by Bills/Receipt, Cash Memos etc)

1. Pre Hospitalisation Benefits

(Within 30 days prior to admission in the hospital) 

2. Hospitalisation Benefits 

3. Post- Hospitalisation Benefits

(upto 60 days from Date of Discharge) 

Total

CONSENT FORM

From:
Patient’s Name and address:

To:
Whomsoever it may concern: (Hospital/Doctor)

Madam/Sir,
I hereby authorize MDIndia Health Insurance TPA Pvt. Ltd.  representatives free and unlimited access to seek
medical information (Indoor case papers, reports, documents, including photocopies thereof / pertaining my,
admission / treatment) from any hospital / medical practitioner from which or whom I have at any time sought or shall
seek medical attention concerning any disease/ sickness, ailment or injury, which affects my physical or mental health.  

Yours faithfully,

Signature of the Patient

22

Reward Your Curiosity

Everything you want to read.
Anytime. Anywhere. Any device.
 Read free for 30 days

No Commitment. Cancel anytime.

Share this document

    

You might also like

Document 2 pages

Claim Form- IPD

Eswar Kiran Reddy
No ratings yet

Document 2 pages

E-MEDITEK
Shah Abhi
No ratings yet

Document 3 pages

Claim Form
Khameer L Shah
No ratings yet
Document 5 pages

Mumbai Claim Form

sunsangra
No ratings yet

Document 2 pages

Claim_form - 001
nitinmisra77
No ratings yet

Document 2 pages

AXA Reimbursement Claim Form

rajkamal eshwar
No ratings yet
Document 2 pages

new-axa-form
Azrul Azuar Azrul Azuar
No ratings yet

Document 2 pages

Physiomodalities Catlog New

RK
No ratings yet

Document 5 pages

Ahmedabad Claim Form

Firdaus Panthaky
No ratings yet
 Document 1 page

020816-Hospital-Treatment-Form
Subhadip Maity
No ratings yet

Document 4 pages

Claim_Form - Mediassit
Kashish Bangalore
No ratings yet

Document 3 pages

IFFCO MediClaim Form

hari198902234
No ratings yet

Related titles

Document Document Document Document Document Docume

Claim Form- IPD E-MEDITEK Claim Form Mumbai Claim Claim_form - 001 AXA
Added by Eswar Kira… Added by Shah Abhi Added by Khameer L… Form Added by nitinmisra77 Reim
Added by sunsangra Added

0 ratings 0 ratings 0 ratings 0 ratings 0 ratings 0 ra

About Support Legal Social

About Scribd Help / FAQ Terms Instagram

Press Accessibility Privacy Twitter

Our blog Purchase help Copyright Facebook

Join our team! AdChoices Cookie Preferences Pinterest

Contact us Publishers Do not sell or share my

personal information
Invite friends
Gifts

Scribd for enterprise

Get our free apps

Audiobooks • Books • Documents • Magazines • Podcasts • Sheet music

Language: English

Copyright © 2023 Scribd Inc.