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Tuesday 31 May 2016

CGHS Medical Reimbursement Form

ANNEXURE I

1
CGHS Token No. and Place of issue

2
Validity of CGHS Token Card & entitlement
From ___________ to ___________
     Private / Semi Private / General
3
Full Name of the Card Holder
(BLOCK letters)

4
Status (Govt. Servant / Pensioners / Other

5
The following documents are submitted [Please tick (P) the relevant column
a)     Medical 2004 Form


YES/NO
b)    Photocopy of CGHS Card
YES/NO
c)     No. of Original Bills enclosed

d)    Copy of discharge summary
YES/NO
e)     Copy of referral by Specialist/CMO
YES/NO
f)     Whether the hospital has given break-up for lab investigations
YES/NO
g)    Original papers have been lost.  The following documents are submitted
I)              Photocopies of claim papers
II)             Affidavit on Stamp Paper


YES/NO
YES/NO
h)     In case of death of card holder, the following documents are submitted -
I)              Affidavit on Stamp paper
II)             No objection from other legal Heirs on Stamp papers
III)            Copy of Death Certificate



YES/NO
YES/NO
YES/NO


Signature of CGHS Card Holder
Dated: _______________
Tel.No. (O)________________
(R )________________
E-mail Address:________________________



Name of the Bank _______________________ Branch __________________________
S.B.Account No._________ Branch MICR Code _______________________________
Tel.No.of Bank Branch ____________________________



CENTRAL GOVERNMENT HEALTH SCHEME

MEDICAL 2004 FORM FOR REIMBURSEMENT OF
MEDICAL CLAIMS OF CGHS BENEFICIARIES 
Computer No.
[To be filled by the claimant]

1
CGHS Token No. and Place of issue

2
Validity of CGHS Token Card & entitlement
From ____________ to ____________
        Private / Semi Private / General
3
Full Name of the Card Holder
(BLOCK letters)

4
Full Address



5
Telephone No.
(O)
(R)
6
E-mail address, if any

7
Name of the Bank

Branch & SB Account No.


Branch MICR Code

Tel. No. of Bank Branch

8
Name of the Patient &
relationship with the card holder


9
Status tick (P) – Govt. Servant / Pensioner / Serving employee or Pensioner of Autonomous Body/Member of Parliament/Ex-MP/Ex-Governor/Former Judge of Supreme Court/Former Judge of High Court/Freedom Fighter/Legal Heir/Others
10
Basic pay / Basic Pension

11
Name of the Hospital with Address
a)     OPD Treatment and or investigations
b)     Indoor Treatment

12
Date of Admission      (in case of Indoor-
Date of Discharge         treatment only)


13
Total Amount claimed
a)     OPD Treatment
b)     Indoor Treatment


14
Details of Referral

15
Details of Medical advance, if any.


DECLARATION

     I hereby declare that the statements made in the application are true to the best of my knowledge and belief and the person for whom medical expenses were incurred is wholly dependent on me.  I am a CGHS beneficiary and the CGHS card was valid at the time of treatment.  I agree for the reimbursement as is admissible under the rules.

Dated: _______________

Signature of CGHS Card Holder

NOTE: Misuse of CGHS facilities is a criminal offence.  Suitable action including cancellation of CGHS Card shall be taken in case of willful suppression of facts or submission of false statements.  Suitable disciplinary action shall be taken in case of serving employees.



You Can Fill the Online Form HERE

Sunday 29 May 2016

CEA bill form active

CHILDREN EDUCATION ALLOWANCE BILL FORM

Online CEA form can be filled up here

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  LOKPAL ASSET LIABILITY FORM:

 The Lokpal  Form Can be Access for Online Edit /filling HERE