{"id":848,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY","purpose":"claim","insurer":{"slug":"galaxy-health-insurance","name":"Galaxy Health Insurance Company Limited"},"source_pdf":"https://www.manipalcigna.com/documents/20124/0/MCHI_Request for Cashless Part C/69278b71-8911-7bce-e2e0-fe262a07e887?t=28","sha256":"c2c8bb7b06676523bff5646bebaf2a70092fa70af5ddee046583437a7ad81e92","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or patient to request cashless hospitalisation under their health insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["The issue of this form is not an admission of liability","Use original documents only","Patient declaration must be signed in presence of hospital representative","Hospital must send all documents within 7 days of discharge","No additional amount to be collected from insured beyond agreed package rates except specified exceptions"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY","submit":{"to":"TPA / Insurance Company","how":"sent within 7 days of patient's discharge","address":""},"purpose":"claim","sections":[{"title":"To be filled by the Insured / Patient","fields":[{"help":"","type":"text","label":"Name of the Patient:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender:      Male             Female          Third Gender","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Enter age in years and 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History of any Chronic Illness, if yes (since month / year)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Diabetes:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Heart Disease:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Hypertension:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Hyperlipidemias:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Osteoarthritis:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Asthma / COPD / Bronchitis:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Cancer:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Alcohol or Drug 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Number:","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Patient's / Insured's Signature:","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email ID (optional):","options":[],"required":false,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"HH:MM format","type":"text","label":"Time:","options":[],"required":true,"pdf_field":""}],"filled_by":"patient / representative"},{"title":"Hospital Declaration","fields":[{"help":"Hospital official seal","type":"signature","label":"Hospital Seal","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Doctor’s Signature","options":[],"required":true,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"HH:MM format","type":"text","label":"Time:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["All valid original documents to be sent to TPA / Insurance Company within 7 days of the patient's discharge"],"applies_to":"health insurance cashless hospitalisation requests","attachments":["Test reports if injury/disease caused due to substance abuse/alcohol consumption","All original documents pertaining to hospitalisation","Final Bill & Discharge Summary signed by patient"],"declarations":["Patient agrees hospital will submit all original hospitalisation documents to Insurer/TPA after discharge","Patient agrees to sign Final Bill and Discharge Summary before discharge","Payment to hospital governed by policy terms; patient liable if insurer/TPA does not settle","Patient will pay non-medical and non-covered expenses","Patient agrees to abide by policy terms and indemnify insurer/TPA if false information is given","TPA does not guarantee hospital service quality","False or untrue statements will forfeit claim rights","Patient agrees to indemnify hospital for expenses not reimbursed by insurer/TPA","Patient consents to KYC verification by insurer/TPA","Hospital agrees to allow TPA/Insurer to verify documents and send originals within 7 days","Hospital agrees no extra amount will be collected beyond agreed package rates except non-admissible costs","Hospital agrees to abide by MoU terms and take responsibility for delays or discrepancies"],"dropped_labels":3},"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/848-request-for-cashless-hospitalisation-for-health-insurance-policy"}