Health Insurance Claim Form (Page 2 of 2) in pdf

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CONSENT REQUIREMENT FOR ACCESS TO TREATMENT PAPERS / INDOOR CASE SHEETS / MEDICAL RECORDS / INVESTIGATOR VISIT

Dear Sir / Madam,

In order to proceed with your claim, Bajaj Allianz General Insurance may need to see your health records. Our doctors may need to

review all your medical records including admission notes, treatment sheets, indoor case papers, investigation reports, prescriptions

and all other documents present in the hospital case file. This will facilitate faster processing and adjudication of your claim. You are

requested to sign the authorization form below to allow Bajaj Allianz General Insurance access to the above medical records.

AUTHORIZATION FORM FOR ACCESS TO TREATMENT PAPERS / INDOOR CASE SHEETS / MEDICAL RECORDS / INVESTIGATOR VISIT

Medical Director

_____________________________________________________________

Dear Sir / Madam,

I _______________________________________________________________ (Name of Patient) was admitted in your hospital from

__________________________ to ___________________________. I am insured with Bajaj Allianz General Insurance as per the policy

details given overleaf.

I hereby authorize Bajaj Allianz General Insurance or any agency / individual authorized by them to obtain copies or review in person all

my medical records including but not limited to admission notes, treatment sheets, indoor case papers, investigation reports, prescriptions

and all other documents present in the hospital case file. Details related to my past hospitalisations in your hospital can also be provided

/ shown to Bajaj Allianz or its authorized representatives.

Verification of the above consent can be obtained from me at _____________________________________ (Patient / Relative Phone

Number)

Name of Patient / Relative: ______________________________________________________

Relationship with Patient: _______________________________________________________

Signature of Patient / Relative: ___________________________________________________

Date: _______________________________________________________________________

Health Insurance Claim Form Page 2