Form for availing Medical Facilities under CGHS or Fixed Medical Allowance after retirement.
This form alongwith undertaking has been issued by Department of Pension and Pensioners Welfare vide OM dated 31.01.2018. You may select the text of form and paste in any word processor like MS Word or you may download the image of form given below or may download the PDF by the link given below.
UNDERTAKING
I , ______________ a retired employee of _____ (Office Address) ___________ declare that I am residing at _______________ (Residential Address indicated in PPO) ________________, which area is not covered under CGHS or any corresponding Health Scheme administered by the Ministry/Department of , _________________________ (as the case may be). I have also not obtained and do not wish to obtain a CGHS Card for availing out-door facilities under CGHS/Corresponding Health Scheme of other Ministries/Departments from any dispensary situated in an adjoining area.
Signature_____________________________
Name of pensioner: ____________________
PPO No. _____________________________
Address: _____________________________
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Form for availing Medical Facilities under central Government Health Scheme
or Fixed Medical Allowance after retirement.
| 1. I reside/will be residing at the following address: | ||||
| Flat/House No/Bldg. Name |
Street/Locality | |||
| Village & Post Office/ Block |
City & District | |||
| State | Pin Code | |||
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2. I opt the following facility
(Please tick any one of the following) |
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| i. I will be residing in a CGHS area and would be availing CGHS facility |
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| ii. I will be residing in a CGHS area but would not be availing CGHS facility, I understand that I will not be eligible for Fixed Medical Allowance (FMA) |
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| iii. I will be residing in non-CGHS area but would be availing CGHS facility for In-patient Department (IPD) and Out-patient Department (OPD) treatment. I will not be eligible for FMA |
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| iv. I will he residing in a non-CGHS area but would be availing CGHS facility for 1PD treatment only by payment of CGHS contributions. I will also avail FMA for OPD treatment |
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| v. I will be residing in a non-CGHS area and would not be availing CGHS facility for both IPD treatment and OPD treatment. I will avail FMA. |
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| vi, I will avail medical facilities available to spouse/family members who is an employees/pensioner of Govemment/PSU/Autonomous Body. I will not avail CGHS facility and FMA |
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| vii. Avail medical facility of previous organization. I will not avail CGHS facility and FMA |
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This is my one time change in option as provided in the Rules and it
supersedes the earlier option given by me. I understand that I shall not be able to change this option again (Strike out this item if not applicable |
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| Name of the retiring employee/pensioner: | Mobile No. |
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(Signature of head of office)
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(Signature of applicant)
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DoP&PW Order dated 31.01.2018 –
COMMENTS