NON-HOSPITAL (OPD) CLAIM FORM · non-hospital (opd) claim form tata institute of social sciences...
Transcript of NON-HOSPITAL (OPD) CLAIM FORM · non-hospital (opd) claim form tata institute of social sciences...
NON-HOSPITAL (OPD) CLAIM FORM
TATA INSTITUTE OF SOCIAL SCIENCESV.N. PURAV MARG, DEONAR, MUMBAI 400 088
THE ORIENTAL INSURANCE COMPANY LIMITED
ANURAG BUSINESS CENTRE202, 2nd floor, W.T.Marg, Next to Amar Theatre
Chembur, Mumbai 400071
GROUP HEALTH INSURANCE POLICY NO. (124291 / 48 / 2016 / 173)
VALIDITY PERIOD : 11/6/2015 to 10/6/2016
Student Name (In CAPITAL LETTERS) : …........................................................................................................................................
Student Bank A/c No. (refer point no. 5 below):...................................................... Name of the Bank: ….............................................
Branch:........................................................................................ IFSC Code No. ….........................................................
Mobile No. FOR OFFICE USE ONLYEmail ID LOT YEAR AND NO. CLAIM NO.
RESIDENTIAL ADDRESS
Insurance Card No (HI ID):
ENROLLMENT NO. AGE (YEAR)
NAME OF PATIENT (IN CAPITAL LETTERS) : PERIOD OF ILLNESS
FROM (DATE) TO (DATE)
NAME OF ILLNESS (IN CAPITAL LETTERS) :
NATURE OF EXPENSES SUB-ITEMTOTAL AMOUNT
INCURRED (in Rs.) R E M A R K S
(A) DOCTOR’S CONSULTATION FEES
1) --------- NO. OF CONSULTATIONS @ Rs…………………..
(B) 1) MEDICINES GIVEN BY DOCTOR
2) INJECTIONS GIVEN BY DOCTOR
3) MEDICINES BOUGHT FROM CHEMISTS
4) INVESTIGATION CHARGES
GRAND TOTAL (Rs.)
I HEREBY DECLARE THAT THE FOREGOING STATEMENTS ARE TRUE IN EVERY RESPECT AND ARE MADE WITHOUT ANY RESERVATION.I ALSO DECLARE THAT I DO NOT GET ANY MEDICAL BENEFITS FOR THE ABOVE ILLNESS FROM ANY OTHER SOURCE.
SIGNATURE OF STUDENT: DATE :
IMPORTANT
1) ALL FIELDS IN THIS FORM ARE MANDATORY.
2) Please send the claim within 30 days from the date of treatment/purchase of medicines.
3) Please attach all Original Prescriptions, Medical Bills, Stamped Payment Receipts from Doctor, Investigation Reports etc. with the claim form.
4) Please ensure that correct Enrollment No. and the Bank details are mentioned, otherwise claim will be rejected.
5) Please provide photocopy of cancelled cheque of your bank account showing student's Name, A/c No., Branch & IFSC code or legible/clear photocopy of first page of passbook mentioning student's Name, A/c No., Branch & IFSC code.