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Star Health

This document is a request form for cashless hospitalization under a health insurance policy from Star Health and Allied Insurance Company Limited. It includes sections for details about the third-party administrator, the hospital, and the insured patient, requiring information such as personal details, policy number, and contact information. The form must be filled out in block letters and includes a declaration section.

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mmhospitalambalacity
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105 views6 pages

Star Health

This document is a request form for cashless hospitalization under a health insurance policy from Star Health and Allied Insurance Company Limited. It includes sections for details about the third-party administrator, the hospital, and the insured patient, requiring information such as personal details, policy number, and contact information. The form must be filled out in block letters and includes a declaration section.

Uploaded by

mmhospitalambalacity
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034.
Corporate Office -Claims Dept.: No.15, Balaji Complex, Whites Lane, 1st Floor, Royapettah, Chennai-600 014.
Toll free Phone No: 1800 425 2255 Toll free Fax No: 1800 425 5522
CIN: U66010TN2005PLC056649 Emai1:cashless.network@starhea!th.in Website: www.starhealth.in IRDAI Regn. No: 129

REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE


POLICY PART - C (Revised)
(TO BE FILLED IN BLOCK LETTERS)

DETAILS OF THE THIRD PARTY ADMINISTRATOR/INSURER/HOSPITAL.:

a. Name of TPA/lnsurance company : STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

b. Toll free phone number:

c. Toll free fax:

d. Name of Hospital: M.M. HOSPITAL

I.Address 6, POLICE LINE, AMBALA CITY


ii.Rohini ID 8900080021044
iii.e-mail id [email protected]

TO BE FILLED BY INSURED/PATIENT

A. Name of the Patient :

[=iMale [=i Female [=i Third Gender


B Gender:

C. Age: _ _ (Years)/ (Month)


_____

D. Date of Birth: (DD/MM/YYYY)

E. Contact number:

F. Contact number of attending Relative:

G. Insured Card ID number:

H. Policy number/Name of Corporate:

I. Employee ID :

J. Currently do you have any other mediclaim / health insurance: Yes [=i No!=i

i.Company Name:
ii.Give Details:

K. Do you have a family Physician: Yes [=i No!=i

L. Name of the family Physician:

M. Contact number, if any:

N. Current Address of Insured Patient:

0 . Occupation of Insured Patient:


{PLEASE COMPLETE DECLARATION OF THIS FORM)
M.M. HOSPITAL

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