TPA – Health India TPA Insurance TPA Pvt Ltd

CLAIM INTIMATION FORM

Date:
Station: PUNE

Subject:

Patient / Claimant Name:

Gender - / Age:

Policy No: ............................ Policy Holder Name:

ID Card No : .... ................................. Emp No :

(In case of Corporate Policy)

Name of the Hospital:

Probable Date of Admission:

Probable Date of Discharge:

Diagnosis / Nature of Ailment: l

Treating Doctor Name:

Approximate cost for the treatment:

Phone Number of the Policy Holder / Claimant: Mobile: Res:

I ALSO CONSENT AND AUTHORISE THE REPRESENT OF M/S Health India Insurance TPA Pvt. Ltd., TO SEEK
MEDICAL INFORMATION / RELATED TREATMENT DOCUMENTS TO VERIFY FROM THE HOSPITAL / MEDICAL
PRACTITIONER WHO HAS ATTENDED ME DURING HOSPITALISATION PERIOD.

Signature