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 . to 10 c. DETALS OF AILMENT DIAGNOSED (PRIMARY) .
CLAIM FORM - PART B. DETAILS OF HOSPITAL. 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 request form in lieu of PART A.
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.
IRDA Claim Form duly signed by the Insured & Hospital. Part-A: Duly signed by the insured with Claimed amount ,Mobile number & Email ID along with PHS ID. Part-B: Duly signed and stamped by hospital.
Part-B: Duly signed and stamped by hospital Y Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals. N
