Reimbursement Claim Form



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Are you looking for a professional Reimbursement Claim Form? If you've been feeling stuck or lack motivation, download this template now!

Do you have an idea of what you want to draft, but you cannot find the exact words yet to write it down or lack the inspiration how to make it? If you've been feeling stuck, this Reimbursement Claim Form template can help you find inspiration and motivation. This Reimbursement Claim Form covers the most important topics that you are looking for and will help you to structure and communicate in a professional manner with those involved. 

Address Enter the full postal address Include 
Street, City and Pin code 
Phone No Enter the phone number of patient Include STD code with telephone number 

1) E-mail ID Enter e-mail address of patient Complete e-mail address 

DETAILS OF HOSPITALIZATION 
a) Name of Hospital where admited Enter the name of hospital Name of hospital in full 
b) Room category occupied indicate the room category occupied Tick the right option 
c) Hospitalization due to indicate reason of hospitalization Tick the right option 
d) Date of injury/Date Disease first detected / Date of Delivery Enter the relevant date Use dd-mm-yy format 
e) Date of admission Enter date of admission Use dd-mm-yy format 
f) Enter time of admission Use hh-mm- format 
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh-mm- format
I) If injury give cause indicate cause of injury Tick the right option If Medico legal indicate whether injury is medico-legal Tick Yes or No Reported to Police indicate whether police report was filed Tick Yes or No MLC Report Police FIR attached indicate whether MLC report and Police FIR attached Tick Yes or No System of Medicine Enter the system of medicine followed in treating the patient Open Text f) j) Time 

SECTION E - DETAILS OF CLAIM 
a) Details of Treatment Expences Enter the amount claimed as treatment expences In rupees (Do not enter paise values) b) Claim for Domiciliary Hospitalization indicate whether claim is for domiciliary hospitalization Tick Yes or No c) Details of Lump sum/ Cash benefit claimed Enter the amount claimed as lump sum / cash benefit In rupees (Do not enter paise values) d) Claim documents Submitted-Check List indicate which supporting documents are submitted Tick the right option SECTION F - DETAILS OF BILLS ENCLOSED Indicate which bills are enclosed with the amount in rupees SECTION G - DETAILS OF PRIMARY INSURED’s BANK ACCOUNT 
a) PAN Enter the permanent account number b) Account Number Enter the

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