| 3-Claim Form to be Sent to TPA(Specimen of a Claim Form TTK Health Care Services Private Ltd) |
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| 7 Jeevan Bheema Nagar Main Road,HALL IIIrd Stage,Bangalore-560 075 |
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| Claim form Duly Signed |
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Pre Hospitalization Bills & N0(s)of Bills |
| TTK Pre-authorization form |
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Post Hospitalization Bills & N0(s)of Bills |
| Claim Notification |
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Hospital Payment Receipt |
| Discharge Summary |
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Investigation Reports with Dr's request |
| Hospitalization Bills |
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1. MRI Yes / No 2. CT Scan ;Yes/ No |
| Doctors Surgery Certificate if any |
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3. ECG Yes/No 4.X-ray Yes/No 5.US Scan |
| Surgery / Consultation Bills if any |
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Lab Reports with Dr's request N0(s).. |
| Operation Theatre Pharmacy bills |
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of Rep Others if any |
| Medicines bills with Dr's prescription |
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| Previous Policy Numbers if any : |
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| I hereby declare that the above information is true & correct to the best of my knowledge and belief. If I have made any false, fraud or untrue statement, suppression or concealment, my right to claim reimbursement of the expenses shall be forfeited. |
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| I also consent and authorise TTK / Insurance company to seek medical information from any Hospital/ Medical Practitioner who has at any time attended on the insured person. |
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| I hereby declare that I have included all bills/ receipts for the purpose of this claim and that I will not be making any supplementary claim in respect thereof, except the post Hospitalisation claim if any. |
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Date .. |
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Signature of the Claimant |
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