Cashless Request Form
/ Insurance Company within 7 days of the patient's discharge. We agree that TPA / Insurance Company will not be liable to make the payment in the event of any discrepancy between the facts in this form and discharge summary or other documents.
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DETAILS OF PRIMARY INSURED - uhcpindia.com
www.uhcpindia.comCLAIM FORM - PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability DETAILS OF PRIMARY INSURED: (To be filled …
CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL ...
www.uhcpindia.comGUIDANCE 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 Enter the name of hospital Name of hospital in full
CHECKLIST FOR CLAIM SUBMISSION
www.uhcpindia.com1) Do not forget to attach this checklist with the Claim file. 2) Arrange the documents in the same order as in the checklist. 3) Please retain copies of all the documents submitted to us for future reference. 4) For any assistance with any of the above formats, please contact us at customerservice@uhcpindia.com
List of Additional Chief Secretary / Principle Secretary ...
www.uhcpindia.comGovernment of Meghalaya Health Complex, Red Hills, Laitumkhrah, Shillong - 793003 Tel Off: 0364-2500019 E-mail: sampath97@gmail.com Dr. Aman Warr Director of Health Services & CEO Mega Health Insurance Scheme, Health Complex, Red Hill Road, Laitumkhrah- 793003, Shillong, Meghalaya Tele off: 0364- 2507477 Email: ceo@mhis.org.in 24 Mizoram Shri H.
SAMPLE CLAIM FORM PART A REIMBURSEMENT (Please fill …
www.uhcpindia.comI hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited.
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