cashless form-sample · 2019-12-02 · Details of the hospital where the treatment will be taken...
3
Details of the hospital where the treatment will be taken Your policy no. in case of retail policy. Corporate name in case of group policy Must be an active Email ID To be filled by the hospital or doctor in concern Employee ID of organization in case of group policy Page 1 Fam d mily doctor details From your Health ID card
Transcript of cashless form-sample · 2019-12-02 · Details of the hospital where the treatment will be taken...
Details of the
hospital
where the
treatment
will be taken
Your policy no. in
case of retail policy.
Corporate name in
case of group policy
Must be an
active Email ID
To be filled
by the
hospital or
doctor in
concern
Employee ID of
organization in
case of group
policy
Page 1
Family doctor
details
Family doctor
details
From your
Health ID
card
To be filled
by the
hospital in
concern
Page 2
Signature of the
patient/insured person
Please
read very
carefully
Insured Person’s
details
To be filled
by hospital
and treating
doctor
Page 3
Signature of the
patient/insured person
