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Hospitalization Claim Intimation Form

A claim intimation form provides details of a patient seeking insurance claim reimbursement including the patient's name and policy details. It lists the hospital name and admission/discharge dates as well as the diagnosis, treating doctor, and estimated treatment costs. The patient authorizes the insurance TPA representative to obtain medical information and documents directly from the treating hospital/doctor to verify the claim.

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Sushant Jambhulkar
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704 views1 page

Hospitalization Claim Intimation Form

A claim intimation form provides details of a patient seeking insurance claim reimbursement including the patient's name and policy details. It lists the hospital name and admission/discharge dates as well as the diagnosis, treating doctor, and estimated treatment costs. The patient authorizes the insurance TPA representative to obtain medical information and documents directly from the treating hospital/doctor to verify the claim.

Uploaded by

Sushant Jambhulkar
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
  • Claim Intimation Form

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

TPA – Health India TPA Insurance TPA Pvt Ltd CLAIM INTIMATION FORM Date: Station: PUNE Subject: Patient / Claimant Name: Gend

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