CGHS: Medical Reimbursement Claim Form for Pensioners:-
FORM – MRC (P)
(For pensioner beneficiaries)
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL REIMBURSEMENT CLAIM FORM
(To be filled by the Principal Card holder/Claimant in BLOCK LETTERS)
1
- (a) Name of the Principal CGHS Card Holder :
- (b) CGHS Ben ID No. :
- (c) CGHS Wellness Center to which the card is attached :
- (d) Validity of CGHS Card :
- (e) Ward Entitlement – Pvt./Semi-Pvt./General :
- (f) Full Address :
- (g) Mobile telephone No. and e-mail address, if any :
2.
- (a) Patient’s Name :
- (b) Patient’s CGHS Ben ID No. :
- (0) Relationship with the Principal CGHS card holder :
3. Category of pensioner beneficiary – please specify
(Central Govt. Pensioner/Pensioner of Autonomous/Statutory body/Ex- MP/ Ex-Governor/ Former Judge of Supreme Court/ Former Judge of High Court/Freedom Fighter/Legal Heir/Others)
4. Name & address of the hospital / diagnostic center
imaging center where treatment is taken or tests done:
5. Whether the hospital/diagnosticflmaging center is
empanelled under CGHS : Yes/No
6. Treatment for which reimbursement claimed
- (a) OPD/T est & investigations
- (b) Indoor Treatment
7. Whether credit facility was availed. If not.
reasons thereof (clarification may be attached)
8. Whether treatment was taken in emergency : Yes/No
9. Whether prior permission was taken for the treatment : Yes/No
10. Whether subscribing to any health/medical insurance : Yes/No
scheme. If yes. amount claimed/received
11. Total amount claimed
- (a) OPD Treatment
- (b) Indoor Treatment
- (c) Tests/Investigation
12. Nameofthe Bank SBA/c No
Branch MICR Code: IFSC Code
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.
Date:
Place: Signature of the Principal CGHS card holder] Claimant
Documents to be attached
- Photo copy of the CGHS card of the principal card holder along with the patient’s CGl-IS Card.
- Copy of permission letter. if any.
- Emergency certificate (original), in case of emergency.
- Copy of the discharge summary.
- Ambulance Certificate (original). if any.
- Original bills lcash memo / vouchers etc. for the reimbursement amount claimed.
IMPORTANT
Kindly ensure to provide the following information / documents, wherever applicable:
- (a)Obtain Break up of Investigations from the hospital/diagnostic center/imaging center (details and rates of individual tests and the exact number of tests. X-ray films, etc.,) as the reimbursable amount is calculated as per approved rates per test.
- b) In case of loss of original papers, Affidavits as per Annexure I to be submitted. All hotocopies of the bills to be attested by the treating doctor/specialist.
- c) In case of death of the card holder, Affidavit as per Annexure II to be filled and attached to claim reimbursement.
- c) In case of implants. Invoice No. along with sticker with serial number of the implant to be attached.
- d) In case of Coronary Stents, outer pouch of stents is to be enclosed.
- e) In case of replacement of pacemaker / ICD etc., copy of the warranty certificate of earlier pacemaker /ICD may be enclosed.
Note: Misuse of CGHS facilities is a criminal offence. Penal action including cancellation of CGHS card may be taken in case of willful suppression of facts or submission of false claims / statements.
Annexure -l
Draft for Affidavit for Duplicate Claim Papers/bills on stamp Paper
I, …………………………………………..son/wife/daughter…………………………………………… of and resident of
……………………………………………………………………………………have lost / misplaced the original paper or
the same are not traceable. I hereby give an undertaking that I have not received any payment against the original bills/claim papers from any source and that if the original papers are traced, I shall not stake claim against original bills in future and that in the event, I receive any cheque against the original bills in future, I shall return the same to competent authority.
Annexure-ll
Draft for Affidavit on Stamp Paper for claiming medical reimbursement
IN CASE OF DEATH of a CGHS Card Holder
l,………………………husband / wife / son / daughter of Late and………………………………………………………..
resident of………………………………………………………………………………………… hereby submit the medical
reimbursement claim papers pertaining to treatment of my husband / wife / father / mother Late Shri/ Smt……………………….who has expired on……………………………………………………………………….. (copy of
Death Certificate is enclosed).
Late Shri/Smt………………………………………………………….has left behind the following other legal heirs,
none of whom have any objection if the entire reimbursable amount is paid to me.
No Objection Certificate signed by other legal heirs on Stamp paper is enclosed.
=======================================================================
Draft for No Obiection Certificate on Stamp Paper.
We (I)………………………………………………………………..S/o D/o Late Shri…………………………………………..
(II)……………………………………………………………….S/o D/o Late Shri…………………………………………..
(Ill)………………………………………………………………S/o D/o Late Shri…………………………………………..
(–)…………………………………………………………………………………………………………………………………….
(–)…………………………………………………………………………………………………………………………………….
(–)…………………………………………………………………………………………………………………………………….
being the legal heirs of Late Shri/Smt………………………………………………………..have no objection if the
entire amount reimbursable pertaining to the treatment of late Shri / Smt…………………………………………………………..IS paid to Shri/Smt………………………………………………….
(i) (Signature) (ii) ( Signature ) (iii) (Signature)
Name: Name: Name:
Address: Address: Address:
Verified by Notary Public
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