{"id":850,"title":"REQUEST FOR CASHLESS OUT-PATIENT BENEFIT","purpose":"claim","insurer":{"slug":"galaxy-health-insurance","name":"Galaxy Health Insurance Company Limited"},"source_pdf":"https://www.manipalcigna.com/documents/20124/0/MCHI_Claim Form_Outpatient Benefit_HMB/a8ee91e0-af65-f33c-9082-4c912352104e?t=28","sha256":"a80dc8d024d3b4e09c4700272cc25cba4c9484f3f9dbd5262f9bb56f1bf31bc1","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for claiming outpatient benefit under a health insurance policy and is filled by the insured patient and the treating doctor/hospital.","notes":["To be filled in block letters.","Hospital seal must include Hospital ID.","Patient declaration must be signed by patient or representative in presence of hospital.","Use original documents and countersign as per checklist.","This form is for cashless outpatient benefit claims under ManipalCigna Health Insurance."],"title":"REQUEST FOR CASHLESS OUT-PATIENT BENEFIT","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of the Insured / Patient","fields":[{"help":"","type":"text","label":"a. Proposer Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b. Name of the Patient:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"c. Gender (Male/  Female/ Third gender):","options":["Male","Female","Third gender"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"d. Age Years:                       Month","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"e. Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile or landline number","type":"phone","label":"f. Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"As printed on the insurance card","type":"text","label":"g. Insured Card ID Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter your health insurance policy number","type":"text","label":"h. Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"i. Currently do you have any other Mediclaim / Health Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide the other insurance company name","type":"text","label":"Company Name:","options":[],"required":false,"pdf_field":""},{"help":"Provide details of other insurance if applicable","type":"text","label":"Give Details:","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"j. Do you have a Family Physician:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide name","type":"text","label":"k. Name of the Family Physician:","options":[],"required":false,"pdf_field":""},{"help":"Contact number of family physician if available","type":"phone","label":"l. Contact Number, if any:","options":[],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"m. Current address of Insured Patient:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"n. Occupation of Insured Patient:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Consultation and Medical History","fields":[{"help":"Date of outpatient consultation","type":"date","label":"a. Date of Consultation:","options":[],"required":null,"pdf_field":""},{"help":"Provide month/year for each illness if applicable","type":"text","label":"Mandatory: Past History of any Chronic Illness, if yes since month / year)","options":[],"required":true,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Diabetes: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Heart Disease: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Hypertension: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Hyperlipidemias: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Osteoarthritis: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Asthma / COPD / Bronchitis: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Cancer: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Alcohol or Drug Abuse: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Month and year since diagnosis","type":"date","label":"Any HIV or STD / Related Ailments: mm/yyyy","options":[],"required":false,"pdf_field":""},{"help":"Specify other ailments if any","type":"text","label":"Any other Aliment, give details:","options":[],"required":false,"pdf_field":""},{"help":"Amount charged for consultation","type":"amount","label":"b. Consultation charges:","options":[],"required":null,"pdf_field":""},{"help":"Amount charged for investigations","type":"amount","label":"c. Cost of investigation:","options":[],"required":null,"pdf_field":""},{"help":"Amount charged for medicines","type":"amount","label":"d. Cost of Medicines:","options":[],"required":null,"pdf_field":""},{"help":"Total amount claimed for outpatient benefit","type":"amount","label":"e. Total Claimed amount:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Details of Hospital / Clinic","fields":[{"help":"","type":"text","label":"a. Name of the hospital / Clinic:","options":[],"required":null,"pdf_field":""},{"help":"Full address of hospital or clinic","type":"text","label":"i. Address:","options":[],"required":null,"pdf_field":""},{"help":"Hospital's Rohini ID if applicable","type":"text","label":"ii. Rohini ID:","options":[],"required":null,"pdf_field":""},{"help":"Hospital or clinic email address","type":"email","label":"iii. E-mail ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital / clinic"},{"title":"Details to be filled by the Treating Doctor / Hospital","fields":[{"help":"","type":"text","label":"a. Name of the Treating Doctor:","options":[],"required":null,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"b. Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"Describe illness and symptoms","type":"text","label":"c. Nature of Illness / Disease with Presenting Complaints:","options":[],"required":null,"pdf_field":""},{"help":"Important clinical findings","type":"text","label":"d. Relevant Critical Findings:","options":[],"required":false,"pdf_field":""},{"help":"Number of days patient has had the ailment","type":"number","label":"e. Duration of the Present Ailment:                  Days","options":[],"required":null,"pdf_field":""},{"help":"Date of consultation with doctor","type":"date","label":"i. Date of Consultation:","options":[],"required":null,"pdf_field":""},{"help":"Provide past history if relevant","type":"text","label":"ii. Past History of Present Ailment, if any:","options":[],"required":false,"pdf_field":""},{"help":"Doctor's provisional diagnosis","type":"text","label":"f. Provisional Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"ICD 10 code for diagnosis if available","type":"text","label":"i. ICD 10 Code:","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Declarations by Patient / Representative","fields":[{"help":"","type":"text","label":"a)  Patient's / Insured's Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"b)  Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"c) Email ID (optional):","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Time of signing","type":"text","label":"Time:","options":[],"required":false,"pdf_field":""},{"help":"Signature of patient or insured","type":"signature","label":"Patient's / Insured's Signature:","options":[],"required":true,"pdf_field":""}],"filled_by":"patient / insured"},{"title":"Declarations by Treating Doctor","fields":[{"help":"","type":"text","label":"a) Name of the Treating Doctor:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Qualification:","options":[],"required":null,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"c) Registration No. with State Code:","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":["All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient's consultation."],"applies_to":"Out-patient Expenses","attachments":["Duly filled and signed claim form","Outpatient Invoices","Treating Doctor Prescription/Consultation papers","Investigation reports and bills, if any","Medicine bills"],"declarations":["I agree to allow the hospital to submit all original documents pertaining to my treatment to the Insurer / TPA.","Payment to hospital is governed by the Terms and Conditions of the policy; if insurer/TPA is not liable, I will settle the bill.","I will pay all non-medical and non-covered expenses not governed by the policy terms.","I declare that all information provided is true and understand that false information will forfeit my claim.","I understand that TPA does not guarantee the quality of hospital services.","I warrant the truth of all particulars and agree that false statements will forfeit my reimbursement rights.","I agree to indemnify the hospital for expenses not reimbursed by the insurer/TPA.","I authorize the Insurance Company/TPA to contact me via mobile/email for claim updates.","I consent to the Company or its representatives accessing and verifying my KYC documents from the Central KYC Registry or other modes.","Hospital agrees to send all original documents to TPA/Insurance Company within 7 days and take responsibility for clarifications and delays.","Hospital confirms patient declaration was signed in their presence."],"dropped_labels":0},"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/850-request-for-cashless-out-patient-benefit"}