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Claim

This document is a claim form for Safeway TPA Service Pvt. Ltd. It requests information such as the name of the insurance company and policy number, claimant and patient details including relationship, age and sex, dates of admission and discharge from the hospital, room type, total amount claimed, and previous coverage details. The claimant must sign to consent to Safeway obtaining hospital records and warrant that the information provided is true. Supporting documents that must be enclosed with the claim include ID cards, discharge summary, bills, investigation reports, medicine vouchers, records of pre/post hospitalization treatment, and hospital registration certificate.

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Stephen Joy
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© Attribution Non-Commercial (BY-NC)
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357 views

Claim

This document is a claim form for Safeway TPA Service Pvt. Ltd. It requests information such as the name of the insurance company and policy number, claimant and patient details including relationship, age and sex, dates of admission and discharge from the hospital, room type, total amount claimed, and previous coverage details. The claimant must sign to consent to Safeway obtaining hospital records and warrant that the information provided is true. Supporting documents that must be enclosed with the claim include ID cards, discharge summary, bills, investigation reports, medicine vouchers, records of pre/post hospitalization treatment, and hospital registration certificate.

Uploaded by

Stephen Joy
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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CLAIM FORM

SAFEWAY TPA SERVICE PVT.LTD.


6/2, First Floor, Industrial Area,Kirti Nagar New Delhi-15,
Tel : 011-41425671/2511464823,25114822 Fax :011-41425672/912266466797
[email protected]
Name of the Insurance Company: _____________________________________ Policy No.: ________________________

Safeway Id. Card no.:_________________ Nature of illness____________________________________________


Name of the Claimant ______________________________________________________________
Address: ___________________________________________________________________________________________
Contact No:_________________________________ E-mail __________________________________________________
Name of the patient: ___________________________Relation with Claimant_______________ Age: _________Sex: M / F
Date of injury sustained or Disease first detected: DD/MM/YYYY
Hospital Name and address: _____________________________Regd. No. : ______________ No. of Beds _____________
Name and Address of attending Doctor:_____________________________________ Regd. No. ___________________
Admitted on : Date ______________ Time ________________ Discharged on: Date _______________ Time ___________
IPD No. / File No.____________ Room No ________ Type of Room _____________________
Total Amount Claimed: Rs.______________________________________________________________________________
Whether Cashless Facility / claim availed earlier, if yes please provide details:______________________________________
Previous coverage details, if any:____________________________________________________________________
I HAVE NO OBJECTION IN SAFEWAY MEDICLAIM SERVICES PVT LTD. OBTAINING DETAILS OF MY TREATMENT /
COLLECTING DOCUMENTS AND / OR VERIFYING HOSPITAL RECORDS. (THIS MAY BE TREATED AS MY CONSENT FOR
1VERIFICATION OF HOSPITAL RECORDS CONCERNING MY ADMISSION)
I HEREBY WARRANT THE TRUTH OF THE FOREGOING PARTICULARS IN EVERY RESPECT AND I AGREE THAT IF I HAVE
MADE OR SHALL MAKE ANY FALSE OR UNTRUE STATEMENT, SUPPRESS OR CONCEAL ANY MATERIAL FACT, THEN, MY
RIGHT TO CLAIM REIMBURSEMENT OF THE SAID EXPENSES WOULD STAND FORFEITED. I FURTHER DECLARE THAT IN
RESPECT OF THE ABOVE TREATMENT, NO BENEFITS ARE ADMISSIBLE UNDER ANY OTHER MEDICAL SCHEME OR
INSURANCE.

Signature (Insured / Claimant)


In support of the above claim, Please enclose the following documents, in original: -

Copy of ID Card.
Completely filled and signed claim form.
Original detailed Discharge Summary
Final bill of the hospital and the payment receipts in original.
Package Break-up details, (if applicable)
All the investigation reports in original.
All the medicine purchase vouchers with supporting prescriptions in original.
Record of treatment taken in Pre & post hospitalization periods, if any.
Hospital Registration Certificate with local Government authorities.
Copy of Authorization Letter

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