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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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.
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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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