CHECK LIST FOR S SUBMISSIO ON OF CLAI IM

Ple ease attach h this check klist with th he Claim file e. Ar rrange the document ts in the same s orde er as in th he checklist t & keep checking a against the e de esignated box b when you do so o. This wa ay you can n ensure t that you h have not m missed any y do ocuments.
Em mployee Nam me: _______ ___________ __________ __ __EMSL Ca ard No: ____ __________ ___________ _________ Em mployee No: __________ __________ _____Name of o the Insura ance:_ ____ ___________ ___________ _________ Co ontact No: __ ___________ _______Mo obile No: ___ ___________ ___E-Mail ID D: ________ ___________ __________

Ch hecklist for documents s: Please Pu ut a

mark against t the box

O Original Claim m Form duly y signed by you y O Original Main n Hospital bi ill with bill number n & br reak up O Original Disch harge summ mary O Original Hosp pital Paymen nt Receipt with w receipt number Hospital regis stration num mber O Original Phar rmacy and In nvestigation n bills O Original Doct tor Prescript tions In nvestigation reports in original/atte o ested from hospital h Po olice FIR/ Medico M Legal Certificate (MLC) X ray/ Ultraso ound Films Co opy of cance elled cheque e Im mportant Points to remember Ple ease retain duplicate d cop pies of all the document ts submitted d to us for fu uture referen nce. For any assista ance with an ny of the abo ove formats, , please con ntact us at cu ustomercare e@emeditek k.com or call at 0124-44666 666. Ple ease retain a POD copy of o the courie er for trackin ng your cons signment in c case of any delay etc. The above list t of docume ents is indica ative. In case of any oth her docume ent requirem ment as spec cified by the e ins surance com mpany our Do ocument rec covery Team m will contac ct you on rec ceipt of your r claim documents by us s. For Implants used in Ca ataract, Hea art Valve su urgeries, CA ABG, Abdom minal Surger ries, Knee replacement sur rgeries, plea ase submit th he bill from the t vendor for f the prost thetic device e used along g with sticke er.