I,__________,have engaged Tathastu Complete Healthcare Consulting, K 1101, Pragati Savvy Swaraj Phase 2, Off S G Road , Opposite Godrej Garden City,JAGATPUR, AHMEDABAD,Gujarat, 382470, and operating under the brand name “ClaimKar” to undertake preparation of reimbursement claim for [myself/family member having name [.]]. [I am duly authorized to provide sensitive personal data or information, and sign this consent form on behalf, of __________.]
As ClaimKar’s customer, we want you to know that we respect the privacy of your sensitive personal data or information. This consent is being obtained pursuant to the Information Technology Act, 2000, and Rule 5 of the Information Technology (Reasonable security practices and procedures and sensitive personal data or information) Rules, 2011, and is supplemental to ClaimKar’s privacy policy available at: http://localhost/claim/privacy-policy.
I understand that:
- The sensitive personal data or information provided to ClaimKar in whatever form, or through whatever medium, is being collected only in connection with ClaimKar’s business of helping me prepare and submit health insurance claim documents;
- I am responsible for the accuracy of the sensitive personal data or information provided to ClaimKar, and ClaimKar is not responsible if the insurance claim is rejected on account of the provision of inaccurate information;
- ClaimKar is committed to protecting sensitive personal data or information and keeping it secure and confidential while it is being collected or used to assist me and that the use and disclosure of my information will be limited to purpose indicated;
- ClaimKar does not, and will not, sell the sensitive personal data or information shared by me to any person, and only uses the sensitive personal data or information for the purpose indicated;
- ClaimKar shares sensitive personal data or information in accordance with law only with such persons as strictly required to conduct its business;
- ClaimKar retains the sensitive personal data or information provided in data centers controlled by it, till I make a request for its deletion; [Note: Rule 5(4) of the Information Technology (Reasonable security practices and procedures and sensitive personal data or information) Rules, 2011 requires the data to be retained only for such time as required to perform the services for which the data has been collected.]
- I have the right to cancel this consent, and request for deletion of the sensitive personal data or information provided. If I cancel, ClaimKar will no longer use or share my sensitive personal data or information, but this will not apply to the sensitive personal data or information already used or shared or when it is required by applicable law. To cancel, I must send a written notice to ClaimKar by registered post to the address mentioned above, or by email to care@claimkar.com. Upon cancellation, I know that ClaimKar will no longer be able to assist me;
- The approval of my insurance claim is the sole discretion of my insurance provider and I do not have any rights against ClaimKar, and will not hold ClaimKar responsible if my claim is rejected by the insurance provider;
- It is the sole right of the insurance provider to decide the approval amount based on my policy terms and conditions, and ClaimKar is merely assisting me in filing the insurance claim forms, and is not guaranteeing the payment of any amount;
- If the insurance provider rejects the insurance claim, ClaimKar will neither be required to, nor be liable for, refund the service fee paid by me; and
- If I cancel the service before the claim documents are submitted, ClaimKar will return all the sensitive personal data or information shared, and delete it from its servers.
Having read and understood ClaimKar’s privacy policy available at http://localhost/claim/privacy-policy, and having understood the foregoing, I give my consent to ClaimKar to access and use the sensitive personal data or information provided.
Name: __________
Contact number: __________
Date: __________
