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Annexure-B: Claim Form - Opd: (In Block Letters)

This document contains an OPD claim form for MDIndia Health Insurance TPA Pvt. Ltd. The form collects information such as the patient's name, member ID number, address, phone number, nature of illness, period of illness, expenses incurred including bills and receipts for consultation, medicines, tests, and other expenses. The patient must declare the information is correct and they have not claimed reimbursement from other sources, and consents to the insurance company obtaining their medical information from providers. Required documents to attach include original OPD cards, bills, prescriptions, test reports, and discharge documents.

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2K views1 page

Annexure-B: Claim Form - Opd: (In Block Letters)

This document contains an OPD claim form for MDIndia Health Insurance TPA Pvt. Ltd. The form collects information such as the patient's name, member ID number, address, phone number, nature of illness, period of illness, expenses incurred including bills and receipts for consultation, medicines, tests, and other expenses. The patient must declare the information is correct and they have not claimed reimbursement from other sources, and consents to the insurance company obtaining their medical information from providers. Required documents to attach include original OPD cards, bills, prescriptions, test reports, and discharge documents.

Uploaded by

vizag mdindia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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ANNEXURE- B: CLAIM FORM- OPD

O.P.D TREATMENT CLAIM FORM


MDIndia Health Insurance TPA Pvt. Ltd.

1) Name
2) MIN No
3) Address (IN BLOCK LETTERS) :
4) Phone Number
5) Nature of Illness
6) Period of Illness

7) Expenses Incurred
Bill Bill Name of the
Type of Expenses Date No. Hospital/Lab/Medical Shop Amount

a) For Consultation

b) For Medicines
c) For Pathological &
other diagnostic tests

d) Any other
Total Expenses Incurred:
I declare that the given information is correct and that I have not claimed reimbursement for the above expenses incurred
by from any other source.

I also consent and authorize MDIndia Health Insurance TPA Pvt. Ltd./ United Insurance Co Ltd /SAIL to seek medical
information/documents from any hospital /provider who has any time attend on the insured person.

Place:
(Signature of Insured)
Date:

Note : Please enclose the following documents in original along with the claim form :

a) OPD Card of SAIL approved I Govt. Hospital.


b) Chemist/Nursing Home Bills/Receipts and Original prescriptions.
c) All Pathological & other test report and bills, if any.
d) Discharge Voucher duly signed.

All the above should be in original. No Photocopies will be accepted.

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