HOSPITALISATION/REIMBURSEMENT CLAIM FORM
                              
                              
                               
Issuance of this form does not amount to admission of any liability under the claim on the part of the insurers
Policy Holder InformationPatient Information
Name:Name:
Crd Id No.Relation:
Address:UHID of Provider
         Tel:No.
         Pin:      Mobile:        
Bank A/C No.:Bank A/C Name & Add.:
E-mail. Address:
Provider Information
Name:                      Provider Information Number(UPIN/MCI NO.):
Address:City:State:Pin:
Claim Information
Admission Date Time:Notes:             
Patient Status:
First Occurance Date:
Discharge Date: Time:
Patient Paid Amount:
Principal Diagnosis:
Other Diagnosis:
Procedure Code: Disease Code:
Serviceline Information
S.No. Service DescriptionAmountDiscountNet AmountPatient Paid AmountRemarksBlance Due
  Room Charge      
  ICU/CCU/Nursery Charges      
  Doctor's Fee      
  Lab Investigation      
  Radiology      
  Other Investigation      
  Specical Procedure      
  Pharmacy Service      
  OT/Labour Room Service      
  Misc.      
         
List of Enclosures(Please Tic)Comments/Remarks/Objections
 
Pre authorisation/FirstAdmission Report             
 
Discharge Summary             
 
Hospitalization Bills with breakups             
 
Investigation Reports             
 
Consulation bills with Receipt             
 
If Surgery,Surgery bills with Receipt             
 
Medicine bills with prescriptions             
 
OT Pharmacy Bills             
 
Others             
I hereby warrant the truth of the foregoing particulars in every respect& I agree that if I have made or shall make any false or untrue statement,
suppression or concealment my right to claim reimbursement of the expenses shall be absolutely for feited. I further declare that in respect of the
above treatment no benefits are admissible under any other Medical Scheme or Insurance.
I authorize EAST WEST ASSIST PVT. LTD (TPA) / United India Insurance Co. Ltd.
to obtain/verify any medical record or information from hospital authorities necessary to process the claim on my behalf.
it is complesory is give bank details because bank bill transfer the claim amount to your bank account by neft
  
Bank Account NamePolicy Holder/Patient
Bank A/C No.Name:
IFSC CODESignature:             Place
MICR CODEDate: