BEEASSIST HEALTH INSURANCE
REIMBURSEMENT CLAIM FORM

Policy Number: POL-1002
Member ID: M-1002-01
Patient Name: Arjun Mehta
Date of Birth: 30/09/1979
Claim Type: Outpatient
Hospital Name: Sunrise Hospital
Provider ID: PRV-203
Date of Visit: 03/09/2026
Diagnosis: Scar revision consultation
ICD-10 Code: Z41.1
Total Amount Claimed: Rs. 12,500.00
Date of Submission: 10/09/2026
