IRDA Regn.No.129
Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600034.
Phone: 044 – 28288800 Telefax: 044 – 28260062 Website: www.starhealth.in
CORPORATE CLAIMS DEPARTMENT: # No 15,1
st
& 2nd Floor, Sri Balaji Complex Whites Lane, Whites Road, Royapettah Chennai - 600014. Phone 044 2888 6495.
________________________________________________________________________________________________________________________________
CLAIM No :_____________________________________________
PATIENT ADMISSION NO / IP NO / MRD NO:_____________________________________________
To: (Name of the Hospital & Address)
___________________________________
___________________________________
___________________________________
Dear Sirs,
Re: AUTHORISATION TO STAR HEALTH AND ALLIED INSURANCE CO. LTD.,
I have undergone treatment for _________________________________________________________________________________
from _______/_______/__________ to _______/_______/__________ in your Hospital.
I hereby authorize M/s. Star Health and Allied Insurance Company Ltd. and its representatives,
who is my Health Insurer to seek any medical information/records from you or from the Medical
Practitioners who have attended on me in connection with the above ailment and the treatment given.
In case they seek any such information/records/indoor case papers, kindly oblige.
Thanking you,
Yours faithfully,
_________________________________
(Signature of the Claimant)
Address of the Insured: DATE: ________________________
__________________________________________ PLACE: ________________________
__________________________________________
__________________________________________
