MDIndia Careers

MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.

An ISO 9001:2000 Company

Toll Free Customer Care No.: 1 800 233 11 66

Toll Free Cash Less No.: 1 800 233 45 05

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Claim Intimation Form

Policy Information
Name of Insurance Company
Policy No	*	MDID No.	*
Policy Start Date	* DD/MM/YYYY	Policy End Date	* DD/MM/YYYY
Name of Policy Holder
Phone No.	*	Mobile No.	*
Hospitalization Information
Name of Patient	*	Age
Sex	MaleFemale	Diagnosis	*
Admission Date / Time	* DD/MM/YYYY	Probable Date of Discharge	DD/MM/YYYY
Name of Hospital	*	Line of Treatment
Address of Hospital		Hospital Contact No.	*
City	*	State
Name of Treating Doctor
Address of Treating Doctor
Contact No. of Treating Doctor		Treating Dr. Mobile No
Name of Family Physician
Contact No of Family Physician		Family Physician Mobile No
Estimated Expenses
Email ID of Hospital
Any other Relevant Information
Additional Document Attached
intimation submitted By

Terms and Conditions

I hereby authorize MDIndia HealthCare Services(TPA) Pvt.Ltd / Insurance Company / Representative of Insurance Company to obtain my medical record / information from Hospital / Nursing Home / Treating Medical Professionals / family Physicians / diagnostic Centers / Medical Shops Necessary to Process the Claims.

Photo identity of the patient has to be carried to hospital during hospitalisation.
Sign/Stamp of hospital on all papers are mandatory while submitting the file.
Photo identity of the patient has to be attached along with Claim Intimation / Documents.
Non submission of the claim Intimation within stipulated time of policy terms will result the claim as NO CLAIM

I accept all the terms and conditions

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