Transcription of CHECK LIST FOR SUBMISSION OF CLAIM - E-Meditek
1 PleArdedo EmEmCo Ch OOOOHOOInPoX Co Im Ple Foat Ple ThinsFosur ease attachrrange the esignated bocuments. mployee Nammployee No: ontact No: __hecklist for Original ClaimOriginal MainOriginal DischOriginal Hospospital regisOriginal PharOriginal Doctnvestigationolice FIR/ Mray/ Ultrasoopy of cancemportant Poiease retain dr any assista0124-44666ease retain ae above listsurance comr Implants rgeries, pleah this checkdocumentbox when me: _____documentsm Form dulyn Hospital biharge summpital Paymenstration numrmacy and Intor Prescript reports in oMedico Legal ound Films elled chequents to remeduplicate copance with an666. a POD copy ot of documempany our Doused in Caase submit thklist with thts in the syou do so_____Mos: Please Puy signed by yill with bill nmary nt Receipt wmber nvestigationtions original/atteCertificate e mber pies of all thny of the aboof the courieents is indicaocument recataract, Heahe bill from tCHECK he CLAIM filesame ordeo.
2 This wa_____Name oobile No: ___ut a myou number & brwith receipt n bills ested from h(MLC) e documentove formats,er for trackinative. In cascovery Teamart Valve suthe vendor fLIST FOR Se. er as in thay you can__ __EMSL Caof the Insura_____ark againstreak up number hospital ts submitted, please conng your conse of any othm will contacurgeries, CAfor the prostSUBMISSIOhe checklistn ensure tard No: ____ance:_ _____E-Mail IDt the box d to us for funtact us at cusignment in cher documect you on recABG, Abdomthetic deviceON OF CLAIt & keep that you h_____D: _____uture referenustomercarecase of any ent requiremceipt of yourminal Surgere used alongIM checking ahave not m_____nce. e@emeditekdelay etc. ment as specr CLAIM docuries, Knee g with stickeagainst themissed any_____ or cacified by thements by usreplacemener.
3 E y ll e s. t
