N a claim form part a to be filled by the insured the issue of this form is not to be taken as an admission of liablity to be filled in block letters details of primary insured. Section ac in the form, you have to fill in insurance details of the primary policyholder and the patient in section a, b, and c. To be filled by the insured the issue of this form is not. 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 name of hospital name of the hospital in full b hospital id enter id number of hospital as allocated by the tpa c type of hospital indicate whether in networkor non. The issue of this form is not to be taken as an admission of liability. Toll free helpline for service 18001024462 toll free helpline for claims 18004191159. Carry your health benefits in your pocket, with the medibuddy app. Preauth forms for cashless hospitalization preauth forms. Enter the policy number as allotted by the insurance company b sl. Enter the social insurance number or the certificate number of as allotted by the oraganization. Primary policyholder is the person in whose name the policy has been issued, and in case of.
Claim form part b to be filled in by the hospital the. Medi assist claim form hospital patient free 30day. Mediassist tpa health insurance claim process sureclaim. Guidance for filling claim form part b to be filled in by the hospital. Please send this claim form duly completed with all enclosures to. Guidance for filling claim form part b to be filled in by the hospital data element description format a name of the hospital. Discover an easy and seamless way to access your health benefits anywhere, anytime with just. Guidance for filling claim form part b to be filled in by the hospital data element description format section a details of hospital a name of the hospital.
Section b details of insurance history a currently covered by any other mediclaim health insurance yes. Claim form part a to be filled by the insured to be. Enter the social insurance number or the certificate. Guidance for filling claim form part a to be filled in by the insured. Scribd is the worlds largest social reading and publishing site. There are eight sections in medi assist reimbursement claim form also called as part a form identified as section ah. 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 details of hospital a name of the hospital. Ultimate guide to medi assist reimbursement claim process. Selection file type icon file name description size revision time user. Guidance for filling claim form part a to be filled in.