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Alankit Healthcare Claim Intimation Form

The document is a claim intimation form containing details of an insurance claim, including the name and contact information of the insured and patient, hospital details, diagnosis, amount claimed, and type of claim. It requests information such as bank details, date of admission and discharge, documents being submitted, and contains spaces for a signature and office use notes.

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rasiya49
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45 views1 page

Alankit Healthcare Claim Intimation Form

The document is a claim intimation form containing details of an insurance claim, including the name and contact information of the insured and patient, hospital details, diagnosis, amount claimed, and type of claim. It requests information such as bank details, date of admission and discharge, documents being submitted, and contains spaces for a signature and office use notes.

Uploaded by

rasiya49
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

ALANKIT HEALTHCARE TPA LTD.

2E/21, JHANDEWALAN EXTENSION,


NEW DELHI-110055
CLAIM INTIMATION FORM
NAME OF THE INSURANCE COMPANYNAME OF THE INSURED
POLICY NO.
ALANKIT CARD NO.
NAME OF THE PATIENT
AGE

SEX

ADDRESS OF THE INSURED


CONTACT NO.
BANK DETAILS (NAME OF THE BANK AND BRANCH)
TYPE OF A/C (SAVINGS/CURRENT) AND A/C NO.
NAME OF THE HOSPITAL AND ADDRESS
HOSPITAL REGISTRATION NO./ FACILITIES AVAILABLE
DATE OF ADMISSION __/__/____

DATE OF DISCHARGE

__/__/____

DIAGNOSIS
CONSULTANTS NAME AND CONTACT NO.
AMOUNT CLAIMED
DATE OF SUBMISSION OF THE CLAIM/ RECEIPT
TYPE OF CLAIM
TYPE OF DOCUMENTS

(CASHLESS/ REIMBURSEMENT) (MAIN/PRE-POST) QUERY REPLY


(ORIGINAL/PHOTOCOPY)

(DISCHARGE SUMMARY/HOSPITAL BILLS/ RECEIPT OF PAYMENT/FILMS/PRESCRIPTIONS/ MEDICINE


BILLS)
SIGNATURE OF THE INSURED
___________________________________________________________________________________________________
FOR OFFICE USE
RECEIVED DATE
INWARD NO.

__/__/____

RECEIVED BY HAND/BY COURIER/ FROM INSURANCE COMPANY

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