Member Claim Form - GOOD HEALTH INSURANCE TPA | …
Name or the in full As albtted by the TICk Yes or NO Use mm-yy Open Text Tack Yes or NO Name Of the in full Surname. First Middle Tick Male or Number Of and months use dd.mrn the rOht if the roht . others. pbaSo specify. Include Street. City Pin code Include STD with number Name Of hospial in full Tick the Tick tho r6ht Use use hh- mm- format use
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CLAIM FORM - PART A TO BE FILLED BY THE INSURED
goodhealthtpa.comCLAIM 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 request form in lieu of PART A (To be Filled in block letters) DETAILS OF HOSPITAL a) Name of the hospital: a) Hospital ID: c) Name of the treating doctor: e) Qualification:
PRE AUTHORIZATION FORM GOOD
goodhealthtpa.comdo you have a family physician yes / no physician name contact no. 2 to be filled in by insured/patient : details of insured/patient (please also sign the declaration on last page of this form) details of third party administrator and hospital …
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