CLAIM FORM PART’ to ‘tea eaaita dy at Per fae ‘LAIM FORM FOR HEALTH INSURANCE POLICIES HEALTHINSURANCE TPAOF INDIALTD. orict han TRAVEL Ang PERSONAL ACCIDENT: PARTA ‘hein thse eas eerste lly geben eck at) sree DOD GOSS OOOO +s BSOSOo0S55 geermrmone: QODOOOOOSS000o00o00 ates QOD DEOSE SOOOOOGSe so Ceseooo0Ro0000E8ggn00 vee DOD O20 SSS OSS OOOO SSoS000oo0000o9 00089080 SS8SS000oS000S000000000202 QOOO00 000000000000 8 *O000000000000000000 * see 00000 O00 C000000 ete > {nut minty eee naan Cw L]w needa SE) Eo seme COIDICOIOCICOICIOIC ms OOOO OCCA seme IEEE rvenrinenenemmmnete Cee me IG) ED copes] rte ee tet armen I It oimeniereee OOOOO000000000 rao einen mon ee< QO SSOES SOOOGSEESECCESESsooo0o00000eeeG0dcog yout ae CJ] omen EE see] saat EDS ET LITE +O) sem] oe] rae tee] ob Eli sn) Nesp sev] seta] Heat] sen] at] one Joe ay) oéimtémestenso: OOOBQOOSS000 000900999080 00000000000 OOOO DOS SSS 009 So S90 00S SoSsssso0000000000038 1000 DSSS O0CS 0000000 SBS RSRSE0000000000 mea OOGOO ee OOOS0000000 Sse =e ccs cenosraznot oe to weadones IO OOOooSSsSsSsSso05o0o0o sinecerenpie Se E)_Srarenmeny Eines} sermons nen iepsmonie tin] ew] Mein] teeta tients I OO SOC comtmie OE] GE] OO) om O06 GO) ween OO OO) O98) ao eter secaue tthe] Ree teet [Snel Cp] iE Toe ‘neuporus:eFotce [] Yea] Wo mutcrponaroncermamcnes Clos CI me psystimetwediime: [Od Qa TEE 2 50u088 | NN © wou 1 ate ae | ‘hin Boomers Site cwcLne Lentewitinmene Se IIOIOOOO ‘trates me QGOOOOD Benen ance wresterhiotnwene — EIEIO mwticnetsse EIEIO 0 eetewcsminton toy ‘Anis *®OO00009) «00000 « BSG0558 Tew » 0000000 wrmtetmnpeet aon JOO werattonmianen get ee CICIT ciimernmctin maton CTW yen pi ian i : 8 SOOOOCOO tees = GOOOOOO a | 8 =OO00000 s DOOOC00 Freese tne totem emer ¢OOEOEOO vm COO GSSSooo 2 ase vo = 000000 fee" Sia] Bae rant ay ep eee mma tc vee OOOQQO0 000 e0@e~POOOOOODOO00000000 -« DOOD 00 DOOO000000 S0000000 2090090000 000 § ace 00Fenteatae [wt OOOO oo 2 ROR REET ORtert after fase fees CLAIM FORM - PART B HEALTH INSURANCE TPA OF INDIALTD. 19 se of is Porm sto taken a an adission of lity Please inde tho ginal preauharzaton request fori ou of PART A (Tobe Fadi block attr) at eat goenoScnesnAsoonoscnesooooAsoacagsogso kl owe §— QOOOOO00R es ara nang eater: [TST BEOOOOOAIIAC J SOOSEGEE80Ra! og g Quen revesmeo OIOOOOOL ere OOOOOO00000 * marron TO EGR GEES00 0OOS0RS COEee EOoOsOESEOseeee0 vemennniee OOOOOOOO eee a me one EE oe BE OO nomi FE) BG oe ME GE wows I) HE vee HG) BE § iethsnnton Cxepe/C] mameel] omeveL] sienn] ——witenty soenctoown [SIE] EE] mers CII § sateen Onda [] icine pa] cued] vee oooooo0o DETALS OF ALMENT DIAGNOSED PRIMARY) crimp OOOO eee JOOOOOO weomedie OOOO G00 weenie OODOO00 ‘Preectoteaton obi: Lr CMe aprectnorzasonsnar: Cl “fretted gh ae: owtaindensnehier Ie Cae Le Yghecmey sand] Abie onan nde omni deta ic CY CI ee TO DDD «retainer mms oat lp cape ey ag ptdetw ee pen tate gman nag oooooooo ADDITIONAL DETAL IN CASE OF NON NETWORK MOSPTTAL (QNLY LLIN CARE OF wwwsroes OOOODD0000 OOOOD00000000000000000000000 OOOOOOO00d OOOOOOOOoooOoooOoooooooooo00000 e OOOO00000 00000000 Nonoooooooo00000000 eet OOOO vem OOOO O00 etme ewsmee OOOOON00 aime — QOOO OOOO wmemetnoniee IC setae cer One Ome cu Ce Oe se oman ie Camaro een a tay bf aoe ye eto sabons 8 BE oo < <> ter tet iadea eeaita Ane site gem fafties HEALTH INSURANCE TPA OF INDIA LTD. Registered and corporate office ‘Health Insurance TRA of India Lud,2™ Floor, Majestic Omnia Building, A-I10, Sector 4 Noida, Uttar Pradesh ~ 201301 CONSENT FORM From: Patient’s Name and address: Policy no: Hospital IPD no: To: Hospital Name: Madam/Sir, Uhereby authorize TPA representatives/Investigator free and unlimited access to seek medical information (Indoor case papers, reports, documents, including photocopies thereof pertaining my admission / treatment) from any hospital / medical practitioner from which or whom I have at any time sought or shall seek medical attention concerning any disease/ sickness ailment or injury, which affects my physical o mental health, Yours faithfully Signature of the Patient/insured