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    Declaration Form PPN

    Uploaded by

    BOOKREADER_NOW
    Declaration Form PPN

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd

    Declaration Form PPN

    Uploaded by

    BOOKREADER_NOW
    970 views1 page
    Declaration Form PPN

    Copyright

    © © All Rights Reserved

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    PDF or read online from Scribd

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    Declaration Form PPN

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    970 views1 page

    Declaration Form PPN

    Uploaded by

    BOOKREADER_NOW
    Declaration Form PPN

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    of 1
    SIG CRrr kia National Insurance SA_NETWo! ECLARATION FORM (To he filled by the Hospitals) Date of Admissio Name of the Hospital. Address: PATIENT NAME/INSURED NAME (BLOCK LETTERS) AGE/SEX... (To be filled by the insured/policy holder/Attendant) 1. Doyou have an insurance policy? YES/NO Ifyes, then please select: New India/ United India/ National insurance/ Oriental Insurance/others Policy No_ TPA Name. TPA card No: 2, Have you contacted TPA or Insurance Company for cashless facility? YES/NO 3) Whether patient opted for Eligible Room Category under Policy: YES/NO If No, then kindly mention the opted room category: ‘On my own option, | wish to avail above facility and | hereby agree to pay on my free will, after being explained in detail by the Hospital authority in my own and understandable language about the above mentioned Facilty/Procedure/Treatment and associated cost of it, which is over and above the agreed tariff for the treatment. Further, if! opt to go for final bill reimbursement with insurance company, respective insurance company will reimburse only as per agreed tariff for the treatment and balance ‘amount will be borne by me / patient only. Ihave also been explained that when room service of a category other than eligible room rent is availed by the patient, not only the difference in room rent but also an equal proportion of all other charges associated with the treatment shall be borne by me/ patient only Signature: Signature: Name of the Patient/Patient’s attendant: Name of the Hospital Representative &Hospital Seal: Mobile No. PAN / Form 60: Aadhar Card Number.

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