National Insurance Claim Form Part B

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Signature and seal of the hospital authority hospital insured hospital f g d m y y d m y. You can know about intimation of claim to the national insurance company tpa third party administrator national health insurance claim procedure to avail cashless facility national health insurance claim procedure for reimbursement of claims and documents required during claim settlement.

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B ip registration number enter insurance provider registration number as allotted by the insurance provider c gender indicate gender of the patient tick male or female d age enter age of the patient number of.

National insurance claim form part b. C name of the treating doctor. Claim form part b. I also consent authorize tpa insurance company to seek necessary.

The signature of the insured is taken on this form after claim form b is fully filled up by us. Guidance for filling claim form part a to be filled in by the insured data element description format section a details of primary insured a policy no. To avoid unnecessary delay correspondence and trouble this form should be returned within 7 days of its issue to the policy issuing.

B n f details of hospital claim form part b to be filled in by the hospital the issue of this form is not to be taken as an admission of liability please include the original preauthorization request form in lieu of part a to be filled in block letters a name of the hospital. Claim form part a to claim form for health insurance policies other than travel and personal accident part a to be filled by the insured the issue of this form is not to be taken as an admission of liablity details of primary insured. 3 middleton street calcutta 700 071 motor claim form issue of this form is not to be taken as an admission of liability.

To be filled in block letters section a section b b sl. C company tpa id no. With state code g phone no.

Enter the policy number as allotted by the insurance company b sl. Guidance for filling claim form part b to be filled in by the hospital data element description format a name of the hospital. Enter the social insurance number or the certificate number of social health insurance scheme.

Claim form part a to be filled in by the insured the issue of this form is not to be taken as an admission of liability to be filled in block letter a policy no. National insurance company limited regd. Claim form part b to be filled in by the hospital please indude the original preauthorization request form in lieu of part a.

Enter the policy number as allotted by the insurance company b sl. B hospital id c type of hospital c name of treating doctor section a details of hospital e qualification f registration no. Guidance for filling claim form part a to be filled in by the insured data element description format section a details of primary insured a policy no.

Enter the social insurance number or the certificate number of as allotted by the oraganization.

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