Get Safeway Claim Form Part B

This guide provides clear and supportive instructions for filling out the Safeway Claim Form Part B online. Follow these steps to ensure you complete the form accurately and efficiently, facilitating a smooth claims process.

Follow the steps to fill out the Safeway Claim Form Part B online

1. Press the ‘Get Form’ button to download the Safeway Claim Form Part B and open it in your preferred editor.
2. Enter the details of the hospital in Section A. Provide the full name of the hospital, its ID, type (network or non-network), the name and qualifications of the treating doctor, and their registration number along with phone contact.
3. In Section B, fill out the patient's details, including their name, IP registration number, gender, age, date of birth, date and time of admission, and date of discharge. If applicable, indicate maternity details and the total claimed amount.
4. Complete Section C, where you will provide details of the ailment diagnosed, including ICD 10 codes for primary and additional diagnoses, procedures performed, and any co-morbidities present. Indicate whether pre-authorization was obtained and provide any required documentation.
5. For claims involving non-network hospitals, Section D requires you to provide the hospital's address, registration number, PAN, and facilities available.
6. Review Section E, which is specifically for non-network hospitals. Ensure that all relevant information, including the number of inpatient beds, is accurately recorded.
7. Finalize your claim by completing Section F, which includes a declaration by the hospital. Enter the date, place, and provide the signature and seal of the hospital authority.
8. Once you have filled out all sections, save your changes, and you can download, print, or share the completed form as needed.

Start completing the Safeway Claim Form Part B online today.