वीओ चिदंबरनर पोर्ट ट्रस्ट - काम करने वाले कर्मचारियों के लिए सम्मानजनक चिकित्सा कोष का रूप

Department* :

Name of the Employee * :

Email ID * :

* *

Designation* :

Employee No* :

Medical ID No * :

Name of the Patient * :

Relationship with Employee

Self or Spouse Dependent

In case of dependent of the Employee

a) Whether name has been enrolled in the Medical Identity Card :

b) Date of Birth and Age of the Dependent (Copy of Medical ID card failing which details available in medisoft system to be enclosed) :

c) Below 25 years/Above 25 years :

d) Whether the monthly income is limited as per the CS (MA) rules i.e. Rs.3900/-+ amount of the Dearness relief on the basic Pension of Rs.3900/- as per pay revision orders for Port. :

Name & place of the Hospital* :

Period of Treatment* :

Hospital Type :

Referral Hospital Non Referral Hospital

In case the treatment was at referral Hospital, whether the treatment was recommended by the Medical Department* :

In case the treatment was at Non referral Hospital, whether intimation was given by the Employee about the present treatment taken :

Yes No

If Yes, date of intimation & Copy of the Intimation to be enclosed* :

Whether the Hospitalisation was due to Emergency situation or Normal * :

Total Bill Amount claimed

Rs* :

Rupees in words * :

Enclosures

a) No of Original Bills

b) Medical reports

c) Certificates(A&B)

d) Copy of Medical ID card or details in medisoft system

e) Copy of the reference letter

Declaration Form

I also declare that the information furnished above is true to the best of my knowledge and belief.

Date * :

Word Verification* :

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* - Please fill out all the required fields before submitting the form.