Αποτελέσματα Αναζήτησης
GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital) DATA ELEMENT. DESCRIPTION. FORMAT. SECTION A - DETAILS OF HOSPITAL. a) Name of the hospital: Enter the name of hospital.
DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY) 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.
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. Y.
Part-B: Duly signed and stamped by hospital. Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals. 2. In case of No Intimation / Delay Intimation & Delay in submission of claim, a letter from insured is required stating reason for the same.
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.
CLAIM FORM FOR HEALTH INSURANCE POLICIES PART B (TPA B Part)(30_07_20).cdr.
Part-B: Duly signed and stamped by hospital Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals. Policy Copy ( if individual policy)
