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Show details Hide detailsBeen refunded to beneficiary through cash/cheque/DD the preauthorization is __________________________ (Preauth Number) has been approved to us. 2. This is also to certify that Rs. _____________________________________ (Rs. In words ________________________________________) has been paid to beneficiary towards travelling charges. Signature/Thumb impression of patient Signature of Arogyamitra 1 Signature of SAMCO Arogya Karnataka (Eligible patient) Preauthorisation-Request for.
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