Get Pre Authorization Form For Cashless Claim - Hdfc Ergo

This guide provides comprehensive instructions for filling out the Pre Authorization Form For Cashless Claim from HDFC ERGO online. The process is straightforward, ensuring users can efficiently provide the necessary information required for cashless hospitalization.

Follow the steps to complete the form accurately.

1. Click 'Get Form' button to obtain the form and open it in your selected tool or editor.
2. Fill out the details of the third-party administrator at the top of the form. Ensure all fields are filled in capital letters, including the name of the TPA, toll-free phone number, and fax number.
3. In the section labeled 'To be filled by insured/patient', enter the patient's full name (first, middle, and last name), gender, age (in years and months), and date of birth. Provide the patient's contact number and the contact number of an attending relative, along with the insured member ID card number and policy number.
4. Indicate if the patient currently has any medical or health insurance coverage and specify the company name and details if applicable. Also, state if the patient has a family physician, and if so, provide their name and contact number.
5. Next, the treating doctor or hospital fills in their information, including the doctor’s name, contact number, nature of illness or disease, relevant clinical findings, duration of the present ailment, and date of first consultation.
6. The doctor should also provide a provisional diagnosis, ICD code, and the proposed line of treatment, indicating whether it involves medical management, surgical management, or intensive care, along with details on drug administration and any surgical procedures.
7. If the hospitalization is due to an accident, complete the relevant fields regarding the circumstances of the injury, including whether it was a road traffic accident and the date of the injury, if applicable.
8. Fill in the details related to the patient's admission, including the date and time of admission, whether it is an emergency or planned hospitalization, expected duration of stay, type of room, and expected costs for various hospital services.
9. In the declaration section, ensure that the treating doctor confirms the details, provides their qualification, and registration number. The patient or insured must sign and date the declaration.
10. Complete any additional declarations required, ensuring that the hospital also acknowledges their responsibilities regarding the hospitalisation documents.
11. Once all sections are filled out, users can save changes, download, print, or share the completed form as needed.

Complete your Pre Authorization Form For Cashless Claim online today for a hassle-free hospitalisation experience.