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.
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 FOR 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 pre-authorization request form in lieu of PART - A. Name of Hospital: b) Hospital ID: SECTION A. DETAILS OF HOSPITAL.
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.
f) Hospitalization due to Injury: Yes No i. If Yes, give cause Self-inflicted. Road Traffic Accident Substance abuse / alcohol consumption. ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this: iii. If Medico legal: Yes No iv. Reported to Police: Yes No. vi.
CLAIM FORM – PART B TO BE FILLED IN BY THE HOSPITAL. 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 Hospital.
