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  • Dully Filled Claim Form Checklist

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    Chandra Rao
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    The document includes a filled claim form and required documentation for an insurance claim related to COVID-19 diagnosis and treatment. It lists attached copies of the patient's government ID and insurance e-card as well as original confirmation of COVID diagnosis. Original receipts for doctor consultation, medicine, and lab tests are also noted as attached, along with prescriptions and lab reports. Signatures and seals are required on offline receipts.

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    Dully filled claim form checklist

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    The document includes a filled claim form and required documentation for an insurance claim related to COVID-19 diagnosis and treatment. It lists attached copies of the patient's government ID and insurance e-card as well as original confirmation of COVID diagnosis. Original receipts for doctor consultation, medicine, and lab tests are also noted as attached, along with prescriptions and lab reports. Signatures and seals are required on offline receipts.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    18 views1 page

    Dully Filled Claim Form Checklist

    Uploaded by

    Chandra Rao
    The document includes a filled claim form and required documentation for an insurance claim related to COVID-19 diagnosis and treatment. It lists attached copies of the patient's government ID and insurance e-card as well as original confirmation of COVID diagnosis. Original receipts for doctor consultation, medicine, and lab tests are also noted as attached, along with prescriptions and lab reports. Signatures and seals are required on offline receipts.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    Dully filled claim form – Part A and Part B form [See attached] ▪ Not applicable

    Duly filled and signed CKYC form along with self-attested valid proof of identity and proof of address of
    employee - Attached

    ▪ Copy of patient Govt id proof and insurance e-card - Attached.

    ▪ Original Covid diagnosed positive confirmation report (must be any one from below) along with doctor
    prescription. – Attached

    Original Doctor Consultation payment receipt with hospital seal and signature along with the original
    doctor consultation notes. ▪ Attached

    Original Medicine Payment receipt with pharmacy/pharmacist seal & signature and along with original
    doctor medicines prescription. ▪ Attached

    Original Lab bill Payment receipt with breakup (cost per each test) and original lab reports with each
    bill/report seal & signature by lab along with original Dr Prescription. - Attached

    ▪ Please note the seal and signature will be required in case of offline receipt. For online receipt, it is not
    required.

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