{"id":839,"title":"CONSENT & AUTHORIZATION LETTER","purpose":"claim","insurer":{"slug":"galaxy-health-insurance","name":"Galaxy Health Insurance Company Limited"},"source_pdf":"https://www.manipalcigna.com/documents/20124/0/SuperTopUp-Claim-Consent-AuthorizationLetter/dd641e13-033a-3397-cd24-3a3471e79f6f?t=28","sha256":"3607b55b87941c3f6386df810ad4eae1a48baccc70d524983c9bb0ac3c7c8bcd","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is a consent and authorization letter filled by the insured or proposer to allow the insurer or TPA to obtain necessary medical information and documents from the hospital and related medical providers to expedite the claim adjudication process.","notes":[],"title":"CONSENT & AUTHORIZATION LETTER","submit":{"to":"The Medical Superintendent / Insurance department of the hospital","how":"","address":""},"purpose":"claim","sections":[{"title":"Consent and Authorization Details","fields":[{"help":"Enter the date of filling this consent letter","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital name where treatment was taken","type":"text","label":"Name of Hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital address","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured/proposer","type":"text","label":"I Mr/Ms","options":[],"required":null,"pdf_field":""},{"help":"Enter Date of Admission (DOA), Date of Discharge (DOD), and Inpatient Number (IP No)","type":"text","label":"was under treatment at your esteemed hospital from DOA to DOD under IP No","options":[],"required":null,"pdf_field":""},{"help":"Sign here to give consent","type":"signature","label":"Signature of Insured/ Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/proposer"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["The consent is given voluntarily without any duress, coercion or undue influence by or on behalf of ManipalCigna Health Insurance Company Limited."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"support@galaxyhealth.com","label":"General Support Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/claims/cashless-claim","quote":"(P), #471, Anna Salai, Nandanam,\nChennai - 600 035.\nCIN: U65120TN2023PLC165765 | IRDAI Registration Number: 167\nEmail: support@galaxyhealth.com |\nToll Free Number: 1800 203 0007\nCompany\nAbout Us\nWork With Us\nAgent Registration\nContact Us\nMedia Center\nServices\nNet","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"reimbursement@galaxyhealth.com","label":"Reimbursement Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"Claims\nFor Cashless claims.\ncashless@galaxyhealth.com\nReimbursement Claims\nFor Reimbursement related Claim Assistance.\nreimbursement@galaxyhealth.com\nCashless Everywhere Claims\nGet Cashless facility for claim in Non-Network Hospital.\nanywherecashless@galaxyhealth.com\nH","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 203 0007","label":"Toll Free Number for Claims","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/claims/cashless-claim","quote":"Cashless Health Insurance Claim Process | Galaxy Health Insurance\nToll Free Number: 1800 203 0007\nProducts\nHealth Insurance\nGalaxy Marvel\nGalaxy Promise\nGalaxy Twin 360\nArogya Sanjeevani Policy, Galaxy Health Insuranc","fetched_at":"2026-10-20"},{"purpose":"cashless","channel":"email","value":"cashless@galaxyhealth.com","label":"Cashless Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"enior Citizens\nFor Claims Assistance.\nsr.citizens@galaxyhealth.com\n1800 203 0007\nCashless Claims\nFor Cashless claims.\ncashless@galaxyhealth.com\nReimbursement Claims\nFor Reimbursement related Claim Assistance.\nreimbursement@galaxyhealth.com\nCashless Everywhere Cla","fetched_at":"2026-10-20"},{"purpose":"cashless","channel":"email","value":"anywherecashless@galaxyhealth.com","label":"Cashless Everywhere Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"nce.\nreimbursement@galaxyhealth.com\nCashless Everywhere Claims\nGet Cashless facility for claim in Non-Network Hospital.\nanywherecashless@galaxyhealth.com\nHospital Empanelment\nFor Hospital Network and Empanelment Enquiry.\nserviceprovider@galaxyhealth.com\n044 4001 7232\nMonda","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/galaxy-health-insurance/839-consent-and-authorization-letter"}