CONSENT FORM

I, __________, have engaged Oasis Claims Management and Services Pvt Ltd, having its Working/Corporate office at 403 Palladium Business HUB, Opp 4D Square Mall ,Chandkheda , Ahmedabad , Gujarat 382424 and operating under the brand name “Claims Made Simple ” 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 Claims Made Simple’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 Claims Made Simple privacy policy available at: https://ClaimsMadeSimple.in/privacy-policy/.

I understand that:
The sensitive personal data or information provided to Claims Made Simple in whatever form, or through whatever medium, is being collected only in connection with Claims Made Simple 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 Claims Made Simple, and Claims Made Simple is not responsible if the insurance claim is rejected on account of the provision of inaccurate information;
Claims Made Simple 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;
Claims Made Simple 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;
Claims Made Simple shares sensitive personal data or information in accordance with law only with such persons as strictly required to conduct its business;
Claims Made Simple 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, Claims Made Simple 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 Claims Made Simple by registered post to the address mentioned above, or by email to care@Claimsmadesimple.org. Upon cancellation, I know that Claims Made Simple 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 Claims Made Simple, and will not hold Claims Made Simple 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 Claims Made Simple 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, Claims Made Simple 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, Claims Made Simple will return all the sensitive personal data or information shared and delete it from its servers. Having read and understood Claims Made Simple privacy policy available at https://Claims Made Simple.in/privacy-policy/, and having understood the foregoing, I give my consent to Claims Made Simple to access and use the sensitive personal data or information provided.
Name: __________
Contact number: __________
Date: __________
Claims Made Simple is not regulated by IRDA and does not have any tie up with Insurance Company or Third party Administrator