ANNEXURE- A: CLAIM FORM -IPD

MD
CLAIM FORM
the claim on the part of the insurance)
(Issuance of this form does not amount to adnission of any liability under

1.Name of the Patient (In Capitals):

2. MIN No.

3. Detail of theperson undergoing treatment:

(a) Name of Patient && relationship to the insurcd:
(c)Phone No.:
(b) Date of Birth:
(d)Mobile No.: (c) E-Mail-LD.
(0 Residential address:

4. Nature of Disease/illness contracted or injury suffered:

$. Date of injury sustained or Disease/ illness first detected
6. (a) Name of the Hospital/ Nursing Home/Clinic:
(b) Address of the Hospital/ Nursing Home/Clinic:
State/ Union Territory
(c) Registration no:
(b) Date of Admission: (c) Date of Discharge:

7. Total Amount Claimed: Rs.

Ihave incurred on the treatment of disease/illness/accident referred to above the expenses as per the details given by me
in the Schedule of Expenses given overleaf. In support of the above claim, Ienclose the following documents:

Claim Forn Duly Signed: Yes/No Pre Hospitalization bills Nos. Yes No
MDI Pre-Authorization Certificate: Yes/No Post Hospitalization bills Nos. Yes/No
Claim Intimation Letter Yes/No Hospital Payment receipt Yes/No

Discharge Summary Yes/No Hospitalization Bill Yes/No

Yes/No Surgeon's surgery certificate Yes/No
Medicines Bills with Dr's prescription
Operation Theater / Pharmacy Bills Yes/No Surgeon/Consultant's bills Yes/No
Investigation reports with Dr's prescription Yes/No
MRI Nos. Yes/No ECG Nos. Yes/No
CT Scan Nos. Yes/No X-Ray Nos. Yes/No
US scan Nos. Yes/No Other's (If any) Yes/No

Ihereby warant the truth of the foregoing particulars in every respect and lagree that if Ihave made or shallmake any
false or untrue statement, suppression or concealment, my right to clainm reimbursement of the said expenses shall be
absolutely forteited. Ifurther declare that, in respect of the above treatment, no benefits are admissible under any other
Medical Scheme or Insurance.

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 THE UArMANT
Ath ure Aeae for tts of st
Trteile of epenere aimed m
Hnenitsiesti
(Te he suported by Billeecei,Cah Mems eey)

Prr Hopitalieation Rnefit

(Within n daye prin tn admiecirm in the hrspit)

2 Hospitalisntion Benefits

3. Post-Hospitalisation Benefits
(upto 60 days from Date of Discharge)

Total

CONSENT FORM
From:

To:
Whomsoever it may concem: (Hospital/Doctor)
Madam/Sir,
Ihercby authorize MDlndia Health Insurance TPA Pvt. Lid. representatives free and unlimited acces lo veck
medical information (lndoor case papers, reports, documents, ineluding photocopics thereof pertaining my.
admission/treatment) from any hospital /medical practitioner from which or whom Ihave al any time sought on shail
scck modical attention concerming any disease/ sickness, ailment or injury, which affects my physical or mental hcalth.
Yours faithfuily,

Signature of the Patient

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