CENTRAL GOVERNMENT HEALTH SCHEME CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS

1. 2.

CGHS Token No. and place of issue Validity of CGHS Card ( for pensioner) And Entitlement Full name of the Card holder (Block Letters) Status (Govt. Servant\pensioner/other) The following documents are submitted [please tick ( ) the relevant column] (a) Medical 2004 Form (b) (c) (d) (e) Photocopy of CGHS card Essentiality Certificate No. of Original Bills Whether original bills/vouchers have been verified. (f) (g) (h) Copy of discharge summary Copy of Permission letter Whether the hospital has given breakup for lab investigations (i) In the event of original papers having been have you submitted the following:I. II. Photocopies of claim papers Affidavit on Stamp Paper

From ________ to _______ Pvt./Semi. Pvt./General

3. 4. 5.

Yes/ No Yes/ No Yes/ No ______ Yes/ No Yes/ No Yes/ No Yes/ No

Yes/ No Yes/ No

6.

Name of Hospital with address (a) OPD treatment and investigations. (b) Indoor treatment

7.

Date of admission

Date of discharge (In case of Indoor Treatment only) 8. Total amount Claimed (a) OPD Treatment (b) Indoor Treatment

9. 10.

Details of permission Details of advance, if any.

DECLARATION

I hereby declare that 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.

Signature of CGHS cardholder Dated:

MEDICAL 2004 FORM FOR REIMBURSEMEN'I' OF MEDICAL CLAIMS OF CGHS BENEFICIARIES (To be filled by the claimant) CGHS Token No. and place of issue Validity of CGHS Card (for pensioners) And Entitlement Full name of Card Holder (Block Letters) Full address From ______ to _________ Pvt/ Semi Pvt./General

1. 2.

3. 4.

5. 6. 7.

Telephone No. (0) E-mail address, if any Name of the Bank( if payment is to be made through Bank for pensioners only) Branch ______________________ SB A/C No.__________________

( R)

8.

Name of the patient & relationship with the card holder Status tick( ) Government Servant/ Pensioner/ Serving employee or pensioner of autonomous body/ Member of Parliament/Ex-Member of Parliament/Ex- Governor/Former Judge of Supreme Court/Former Judge of High Court/ Freedom Fighter/ Legal Heir/Others Basic Pay/Basic Pension Name of Hospital with address (a) OPD treatment and investigation (b) Indoor Treatment

9.

10. 11.

12.

Date of admission Date of discharge (In case of Indoor Treatment)

13.

Total amount Claimed (a) OPD Treatment (b) Indoor Treatment

14. 15.

Details of Permission Details of Medical advance, if any

DECLARATION I hereby declare that statements made in the application are true to the best of my knowledge & belief and the person for whom medical expenses were incurred 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

ESSENTIALITY CERTIFICATE-CUM-STATEMENT OF EXPENDITURE CERTIFIED BY TREATING SPECIALIST (to be submitted in duplicate)

1.

Name of the patient and relationship with card holder Details of expenditure: OPD Treatment (I) (II) (III) Name of the Hospital Total No. of voucher Amount claimed Diagnosis : : :

2. (A)

(indicate serial number of individual voucher with name and address the shops with date against each sub heading in separate annexure wherever required) Amount claimed Amount admissible (for official use) ________________ ________________

(a) (b)

Medicine Consultation fees (specify number of consultations) Laboratory Charges (break-up in a separate annexure) Disposable Surgi-Sundries Special devices like hearing aid/ artificial appliances etc. (Specify) Miscellaneous (Specify) Total:

______________ ______________

(c)

______________

________________

(d) (e)

_______________ ______________

________________ ________________

(f)

_______________ _______________

________________ ________________

(B)

Indoor Treatment

Diagnosis ____________________________

(To be marked N/A wherever necessary) (Details of Hospital Bill and other vouchers pertaining to the period of indoor treatment) (a) (b) Name of the Hospital with address Period of Bill : From ____________ To ______________

(b)

Amount claimed

(indicate serial No. of individual vouchers with name and address of shops with date against each sub heading in a separate annexure whichever required). Amount Claimed. Amount Admissible (For office use)

(j)

Room Rent: ICU/lCCU/Ward From _____To_____

____________ ____________

__________________ __________________

(ii) Charges for (a) (b) (c) (d) (iii) (iv) O.T. O.T. Consumables Annesthesia Proceedure Medicines Implants like pace-maker Coronary stent etc( details) Artificial devices(details) _____________ ______________ ______________ ______________ ______________ __________________ __________________ __________________ ___________________ ___________________

_______________ _______________

___________________ ___________________

(v) (vi)

Lab. Charges (Break-up given in Annexure) _______________ Spl. Nurse/ Aya, if any Miscellaneous

___________________

(vii) (viii)

________________ __________________ ________________ ___________________ ________________ ___________________

TOTAL

Signature of Claimant, ( ) Name in Block Letters, Address & Telephone No. if any

1. Certified that the relevant bills/vouchers have been verified by me and the expenditure shown above is correct and the treatment services provided are essential and minimum that required for the recovery of the patient. 2. Certified that the services of special Nurse/Aya were required from_________ to_________ and that were absolutely essential for the recovery of the patient. 3. Specific procedure/Operation performed was ___________________________

Signature of the Treating Specialist With official seal

Countersigned by Medical Superintendent of the Hospital with seal (for indoor treatment only).

No.D-12017/l/2006-GM GOVERNMENT OF INDIA INDIA METEOROLOGICAL DEPARTMENT OFFICE OF THE DIRECTOR GENERAL OF METEOROLOGY LODI ROAD, NEW DELHI-II0003. Dated: New Delhi-3; the To, The Medical Superintendent, _______________________ _______________________ _______________________ Sub: Permission for treatment/investigation/hospitalization of CGHS approved rates to _______________________________________________________________ Madam/Sir, _____________________________________________may please be provided with necessary treatment facilities and accommodation in accordance with the status of the Government Servant whose particulars are given below: 1. 2. 3. 4. 5. Entitlement Class: General ward/Semi private ward/Private ward. Contribution of Basic Pay: __________________________________ CGHS Token No. ______________________________________ Dispensary: No. ______________________________________ Entitlement for reimbursement of (a) Angiography Rs.____________ (b) CABG Surgery Rs. _______________________ (C) ____________________ 2007.

The balance amount if any may be recovered from a CGHS beneficiary which is to be borne by him. Necessary bills in this respect excluding diet charges may please be sent to ______________________________________________________________________ in triplicate for payment. Diet charges may please be collected from the patient. Validity of this letter is for 3 (three) months/ 6 (six) months from the date of issue of this letter. Yours faithfully,

( ) Assistant Meteorologist Gr.-II (Admin.) for Director General of Meteorology

DGM UOINo.D-12017/1/2006-GM

Dated: New Delhi-3; the

2007

Copy to: 1. 2. 3. Shri __________________________________ CMO I/C CGHS Disp. No.________________ Guard file.

Assistant Meteorologist Gr.-II (Admin.) for Director General of Meteorology Note:1. Claim should be submitted to office within 3 months from the date of completion of treatment. 2. OPD medicines are not reimbursable.