Get Ghpl Claim Form

Filling out the Ghpl Claim Form is an essential step for users seeking reimbursement for medical expenses. This guide provides clear and detailed instructions to help you navigate each section of the form effectively.

Follow the steps to complete the Ghpl Claim Form online.

1. Press the ‘Get Form’ button to obtain the Ghpl Claim Form and open it in the appropriate editor.
2. Begin with the 'Patient Information' section. Fill in the Card ID, Name, Age, Relationship to Insured, Contact Number, Email ID, Member Covered Since, Hospital/Provider Name, and Provider Code.
3. Next, complete the 'Policy Holder Information' section. Provide your Name, Address, Insurer, and Policy Number.
4. In the 'Information on Illness/Injury and Treatment' section, detail the Ailment/Injury for which treatment was received. Enter the Date of Admission, Date of Discharge, and specify the Time of Admission and Discharge, indicating whether it was AM or PM.
5. Carefully answer questions regarding Road Accidents and Principal Diagnosis. Include the Disease Code if applicable and mention any medico-legal details.
6. Provide necessary treatment details, including the Line of Treatment, Procedure Code, and Treating Doctor Information, including Name, Qualification, and Phone Number.
7. In the 'Bank Account Details' section, fill in the details of the bank account where reimbursement should be credited. This information is mandatory for United India Insurance Co. Ltd customers. Include the Name of Account Holder, IFSC Code, Account Type, Bank Name, and Full Bank Account Number. Ensure to attach a photocopy of the cancelled cheque leaf.
8. Proceed to list the Treatment Costs in the designated section. Itemize services, including Room Charges, Doctor's Fee, Lab Investigations, and any Other Investigations. Fill in the Amount Charged, any Discounts, and calculate the Net Amount, followed by the Patient Paid Amount and Balance Due.
9. Review the Undertaking by the Patient. Confirm the accuracy of the information provided and sign where indicated. Ensure the authorization for the hospital/provider to submit relevant documents to GHPL if required.
10. Finally, complete the checklist of documents. Gather and attach all necessary documentation as per the guidelines provided in the form.
11. Once all sections are completed, save changes, and choose to download, print, or share the form as needed.

Complete your Ghpl Claim Form online to ensure your claim is submitted accurately and promptly.