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.
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