Form for Reimbursement of Medical claims of ECHS Beneficiaries:-
Appendix V
(Ref Para 10 (d)
of B/49779-Outsourcing/AG/ECHS
Dated Mar 2014)
FORM FOR REIMBURSEMENT OF MEDCIAL CLAIMS OF ECHS BENEFICIARIES
| 1. | ECHS Registration No. | __ __ __ ___ __ __ __ __ __ __ __ __ | |
| 2. | Full Name of the Card Holder | ___ __ __ __ ___ __ __ __ __ __ __ __ __ | |
| 3. | Full Address | ___ __ __ __ ___ __ __ __ __ __ __ __ __ | |
| 4. | Telephone No. | ___ __ __ __ ___ __ __ __ __ __ __ __ __ | |
| 5. | E-Mail Address | ___ __ __ __ ___ __ __ __ __ __ __ __ __ | |
| 6. | Name of the Bank ___ __ __ __ ___ __ __ __ __ __ __ Branch ___ __ __ __ ___ __ __ __ __ __ S/B Ac No ___ __ __ __ ___ __ Branch MICR Code __ __ __ __ __ __ __ Tele No of Bank Branch __ __ __ __ __ __ __ | ||
| 7. | Name of the patient & relationship with the card holder __ __ __ __ __ __ ___.. __ __ __ __ __ __ | ||
| 8. | Name of the Hospital with address: | __ __ __ __ __ __ __ __ __ __ __ __ __ __ | |
| (a) | OPD treatment and investigations | __ __ __ __ __ __ __ __ __ __ __ __ __ __ | |
| (b) | Indoor Treatment | __ __ __ __ __ __ __ __ __ __ __ __ __ __ |
| 9. | Date of Admission __ __ __ __ __ __ __ Date of discharge __ __ __ __ __ __ __ | ||
| 10. | Total amount claimed | ||
| (a) | OPD treatment and investigations | __ __ __ __ __ __ __ __ __ __ __ __ __ __ | |
| (b) | Indoor Treatment | __ __ __ __ __ __ __ __ __ __ __ __ __ __ | |
| 11. | Details of Referral | __ __ __ __ __ __ __ __ __ __ __ __ __ __ | |
| 12. | Details of Medical Advance, if any | __ __ __ __ __ __ __ __ __ __ __ __ __ __ | |
| 13. | The following documents are submitted (please tick the relevant column) | |||
| (a) | Photocopy of ECHS Card | : | Yes / No | |
| (b) | No. of Original Bills | : | Yes / No | |
| (c) | Copy of discharge summary | : | Yes / No | |
| (d) | Copy of referral Specialist / SEMO | : | Yes / No | |
| (e) | Whether the Hospital has given breakup for Lab investigations | : | Yes / No | |
| (f) | Original papers have been lost the following Documents are submitted | |||
| (i) Photocopies of claim papers | : | Yes / No | ||
| (ii) Affidavit on Stamp paper | : | Yes / No | ||
| (g) | In case of death of card holder, the following documents are submitted:- | |||
| (i) Affidavit on Stamp paper by Claimant | : | Yes / No | ||
| (ii) No objection from other legal heirs on stamp papers | : | Yes / No | ||
| (iii) Copy of death certificate | : | Yes / No | ||
DECLARATION
I hereby declare that the statements made in the application are true to the best of my knowledge and belief and person for whom medical expenses were incurred is wholly dependent on me. I am a ECHS beneficiary and am agree for the reimbursement as is admissible under the rules.
| Date: | Signature of ECHS Card Holder |
COMMENTS
I am ex-servicemen. I have downloaded the form for reimbursement , but which form appendix V or J. are to be submit
What is the produere if madicine is not Avoilable in ECHS policlinics
My father is a ex servicemen. whats the procedure of claiming the medicine bill? I have downloaded the form, now where to submit, what to do? will u plz explain me the whole procedure.