Fixed Medical Allowance Form N1- For CG Employees covered under NPS and their family members for availing Medical Facilities under Central Government Health Scheme or Fixed Medical Allowance after retirement/ death
(DoP&PW O.M. No. 04/07/2020-P&PW (D) dated 07.02.2025)
FMA FORM N-1
(For Central Government employees covered under NPS and their family members for availing Medical Facilities under Central Government Health Scheme or Fixed Medical Allowance after retirement/ death)
| 1. | I reside/will be residing at the following address:- | Passport size photo of the Applicant |
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| Flat, House No. and Street/Locality |
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| Village & PO | City and District | ||||
| State | Pin Code | ||||
| 2. | No. of years of qualifying service :- | ||||
| 3. | I opt the following facility (tick in the column applicable below) | ||||
| i. | I will be residing in a CGHS area and would be availing CGHS facility | ||||
| 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) | ||||
| 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 | ||||
| iv. | iv. I will be residing in a non-CGHS area but would be availing CGHS facility for IPD treatment only by payment of CGHS contributions. I will also avail FMA for OPD treatment. | ||||
| 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. | ||||
| vi. | I will avail medical facilities available to spouse/family a member who is an employee/ pensioner of Government/PSU/Autonomous Body. I will not avail CGHS facility and FMA | ||||
| vii. | Avail Medical facility of previous Organisation. I will not avail CGHS facility and FMA | ||||
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Note:- This is my one time change in option as provided in 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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4. Details:
| Name of the Retiring Employee/ Family member | |
| In case of Family member give name of the Government employee:- | |
| Relationship with Government employee | |
| Office Address | |
| Present Residential Address | |
| PRAN of the Government employee | |
| Bank Account No. | |
| Bank Address (Branch Name) | |
| IFSC Code |
Undertaking
I โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ, (a retired employee)*/ [family member of the deceased employee โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ., (write name of the deceased employee in case of family member)]* who was working in the office โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ (Complete office Address) declare that I am โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ residing at โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ, which area is not covered under CGHS or any corresponding Health Scheme administered by the Ministry /Department โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ โฆ (as the case may be). I also have not obtained nor wish to obtain any CGHS card for availing outdoor facilities under CGHS/Corresponding Health Scheme of the other Ministry/Department from any dispensary situated in the adjoining area.
Note: * Strike out whichever is not applicable.
Place:-
Date:-
| (Signature of head of office) | (Signature of applicant) |
FMA-Form-N1_page-1
FMA-Form-N1_page-2
Fixed Medical Allowance Form N-2
Fixed Medical Allowance Format N-1
Fixed Medical Allowance Format N-2
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