Medi Assist India TPA Pvt Ltd

CHECK LIST FOR SUBMISSION OF REIMBURSEMENT CLAIM

S No Required Documents to be submited in Original Yes / No

1 Duly Filled Claim form

2 First prescription & consultation paper

3 Hospital Discharge Summary

4 Indoor case papers (If Required)

5 Lab, X-ray, Scan, MRI reports etc.

6 Hospital Final Bill with Breakup Details

7 Authentic Paid Receipts

8 Pharmacy bills along with prescriptions

9 “MLC / FIR Copy” in case of Accident

10 Photo Copy of MA Health Card along with any authentic Photo ID Proof

11 Aadhaar Xerox Copy

12 Pan Card Xerox Copy

13 Canceled Cheque / Bank Account Proof with IFSC Code Number

Note: Above are the minimum required documents for submitting the claim document for Reimbursement
FOLLOWING DETAILS TO BE FILLED

Account Holder Name:

Account No:
Bank
Bank Name:
Details

Bank Address:

IFSC Code:

Corporate Name:

Employee Name:

Patient Name:
Insurance
Employee Code (As Menctioned on Medical Card):
Details

MAID Number (As Menctioned on Medical Card):

Contact Number:

E Mail ID:

Signature