CPR Number

Mobile:
Email:
Provider Name
Treatment date:
Claim Amount:



Remarks:
Remarks:- Health360 will process the reimbursement claim on the basis of provided scan documents, Kindly note that claim will be settled only when we received original documents.

	Online Registration Claim
Online claim No		Name
Cpr No		Class
Corporate Name		Provider Name
Policy No		Policy Start Date		Policy End Date
Treatment Date		Amount

Authorized Signatory