OPD Claim Form
Please fill out all details
First Name ( Poora Naam)
*
Last Name
*
Who is the claim for? (Yeh claim kis k lien hai)
*
Self (Apna)
Mother (Ammi)
Father (Abu)
Spouse (Biwi)
Children (Bachy)
What type of claim is? (Claim ki kea kism hai)
*
Consultation (Mushawarat)
Medicine (Dawa)
Test (Jaanch)
Hospitalization (Hospital me daakhla))
Other (Degar)
Symptoms (Ilamat)
Test Amount in Rs.
Consultation Amount (Mushawarat ki raqam)
*
Consultation Amount is Rs.
Medicines Amount (Dawa ki raqam)
Test Amount in Rs.
Test Amount (Jaanch ki raqam)
*
Test Amount in Rs.
Upload Claim Document & Bills. (Claim k dastavaiz or bills yahn attach karen)
*
First Image
Second Image
Thrird Image
Submit Claim
