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Financial Undertaking: Company/TPA - Refuses The Cashless Facility Due To Any Reason

This document is a financial undertaking signed by Mr. ___________ on behalf of a patient admitting to ___________ hospital. It states that the signer will be responsible for any medical bills not covered by the patient's insurance company/TPA due to reasons like denial of cashless facility, partial approval of bills, or non-admissible charges. Contact details of the signer are also provided.

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Manoj Sakhare
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514 views

Financial Undertaking: Company/TPA - Refuses The Cashless Facility Due To Any Reason

This document is a financial undertaking signed by Mr. ___________ on behalf of a patient admitting to ___________ hospital. It states that the signer will be responsible for any medical bills not covered by the patient's insurance company/TPA due to reasons like denial of cashless facility, partial approval of bills, or non-admissible charges. Contact details of the signer are also provided.

Uploaded by

Manoj Sakhare
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Financial Undertaking

I, Mr.
___________
(relationship: ___) on behalf of patient, Mr./Mrs ___________,
admitted in ___________, Bed No with Registration No ___________, hereby
undertake to settle all the bills of hospitalization, in case my Medical Insurance
Company/TPA ___________refuses the cashless facility due to any reason.
In case of partial approval of the bill, I will pay the portion that is not sanctioned by
the Medical Insurance Company/TPA (E.g. NME, Surcharge, Instrument charges,
Camera, etc.)

Patient/Relative Sign.

I have been explained and I understand that at the time of discharge the TPA may
take 4-5 hours for sanctioning the enhanced amount of approval of the final bill.
I am aware of the Insurance Company/TPA admissible charges by the Insurance
Company/TPA
for
the
procedure. and I agree
that I will pay the non-admissible part Rs.. for which I will not
approach the Insurance Company/TPA or my organization for the reimbursement at
any point of time.

Patient/Relative Sign.

My contact details are as follows:


Telephone No:-

0**-******6

Cell phone No:-

+919******4

Postal Address:.

FROM GIVEN
Date: Time:
.
Signed in the presence of
Ruby Hall Clinic Emp
FROM RECEIVED
Date: Time:
.

NOTE: - I will have no objection to give my indoor case papers to the TPA for billing
procedure, if & when required
Patient/Relative Sign.

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