NIBL Medicash Intimation


Fields marked with * must be filled in. Helpline Number : 0124-4149717
Customer Information
Customer Name:* NIBL Card Number:*
Address:*
Date of Birth(MM/DD/YYYY):*
Contact Number (India):
Mobile (Nepal):
City:*
Mobile (India):
Contact Number (Nepal):
Email Id:*
Hospitalisation details
Purpose:*
Name of the Hospital:
City:
Disease:
Line of Treatment:
Date of Admission(MM/DD/YYYY):*
Date of Discharge(MM/DD/YYYY):*
Prior Appointment with Hospital:* Patient Name:*
Emergency Contact Details
Name:
Email Id:
Relation:
Contact Number:
Country:        
Travel Details
Staying In Hotel / Family:* Name of Hotel:
Contact Detail of Hotel:
Travel City:
  Travel Date(MM/DD/YYYY):*
 
Additional Information (If you wish to share)
I agree to accept all the terms & conditions of NIBLMediCash card.
Disclaimer: NIBL MediCash card is not an Insurance product. The card offers subsidized services at network healthcare providers for medical and healthcare services. The Card member is obligated to pay directly for services availed using NIBL MediCash Card. All Network healthcare providers empanelled with EMGPL are providing concessional services for social cause only