Annexure01(part B)

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File: Annexure01(part B)

claim form part b to be filled in by the hospital the issue of this form is not to be taken as an admission of liability to be filled in ...

Filetype PDF | Posted on 17 Aug 2022 | 4 years ago

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...Claim form part b to be filled in by the hospital issue of this is not taken as an admission liability block letters please include original preauthorization request lieu a details name section network non if fill e c type id treating doctor s u r n m f i t d l qualification g phone no registration with state code patient admitted y ip number age years months male female gender date birth h discharge time ii gravida status delivery j k maternity emergency day care planned home at another deceased total claimed amount ailment diagnosed primary icd codes pcs description procedure diagnosis additional iii co morbidities iv yes pre authorization obtained give reason substance abuse alcohol consumption road traffic accident cause self inflicted hospitalization due injury attach reports...

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Category: Uncategorized / Uncategorized
Posted on: 17 Aug 2022 | 4 years ago
Tag: download pdf, annexure01, part,
Filetype: PDF
File size: 1.15 MB
Views: 101x
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