Form for Clamim Medical Bill - Reimbursement of Medical Bill West B

1 Identity Card(meant for the Scheme) No : 2 : 3 Full Address:-: (i) Office : (ii) Residence : 4 : 5 Pay(Basic + Dearness Pay) : 6 Name of the Hospital with Address : (a) OPD treatment & Investigation : (b) Indoor treatment & Investigation : 7 Date of Admission:-Date of discharge:-(In case of Indoor Treatment Only) : 8 Total Amount Claimed : (a) OPD treatment : (b) Indoor treatment : 9 Details of permission : 10 Details Medical Advance, if any : Date Signature of the Govt. Employee I hereby declare that the statement 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 beneficiary of the West Bengal Health Scheme,2008, and the card issued under the Scheme was valid at the time of treatment. Igree for the reimbursement as is admissible under the rules. Application Form for settlement of claim for reimbursement of W.B. Health Scheme (See sub-clause(1) of clause 12) FORM C (To be filled in by the applicant) DECLARATION Name of the Patient & Relationship with the Govt employee Full Name of the Govt.employee with Designation ( In Block Letters) www.pranab.jiaganj.com 1/512 Details of expenditure (A) OPD Treatment Disgnosis (I) Name of the Hospital (II) Total No. of vouchers (III) Amount claimed (For Official Use) (a) Medicine (b) Consultation fees (Specify number of consultations) ( C) Laboratory charges (Break-up in a separate annexure) (d) Disposable surgical Sundries (e) Special devices like hearing aid/artificial appliances etc.(specify) (f) Miscellaneous(specify) TOTAL Rs. Cont.page 2 Amount Claimed Amount Admissible FORM D Essentiality Certificate-cum-statement of Expenditure Certified by Treating Specialist (See sub-clause(3) of clause 12) (to be submitted in duplicate) (Strike out whichever is not applicable) (Indicate serial number of individual vouchers with name and address of the shops with date against each subheaadin in a separate annexure wherever required) Name of the patient and Relationship with Govt.Employee www.pranab.jiaganj.com 2/5(B) Indoor Treatment Diagnosis (To be marked N.A. wherever not necessary) (Details of Hospital Bill and other vouchers pertaining to the period of indoor treatment) (a) (b) Period of Bill From To ( c ) Amount Claimed:-(i) Room Rent (ICU/ICCU/Ward From To (ii) Charges for :-(a) O.T. (B)O.T.Consumables ( c) Anesthesia (d) Procedure (iii) Medicines (iv) implants like Pacemaker,Joint Replacement, coronary Stent etc.(details) (v) Artificial Devices(details) (vi) Lab Charges(Break-Up given in Annecure) (vii) Spl.Nurse/Ayah, if any (viii) Miscellaneous Total Rs (Signature of Claimant) Name in Block Letters Address 123 Countersigned by Medical Superintendent Signature of the Treating Specialist of the Hospital with Seal(For Indoor treatment only) with official seal (indicate serial number of individual vouchers with name and address of shops with date against each subheaadin in a separate annexure wherever required) Certified that the services of Special Nurse/Ayah were required from ______________________To___________________ that were absolutely essential for the recovery of the patient. Specific procedure/Operation performed was Amount Claimed Amount Claimed Name of the Hospital with Address Certified that the relevant bills/vouchers have been verified by me and the expenditure shown above is correct & the treatment services provided are essential & minimum that required for the recover of the patient. www.pranab.jiaganj.com 3/51 Card No. and place of issue : 2 Entitlement Private Semi-Private General Ward 3 : 4 Designation : 5 The following documents are submitted : (Please tick[√] the relevant column) : (a) Photocopy of the Identity : Yes/No (b) Essentiality Certificate : Yes/No © Number of original bills : Yes/No (d) Whether original bills/vouchers : Yes/No have been verified (e) Copy of discharge summary : Yes/No (f) Copy of permission letter : Yes/No (g) Whether the Hospital has given break :-Yes/No up for lab investigations (h) Original papers have been lost the : Yes/No following documents are submitted (I) Photocopies of claim paper : Yes/No (II) Affidavit on stamp paper : Yes/No (i) In case of death of card-holder the : following documents are submitted (I) Affidavit on stamp paper claimant : Yes/No ( II) No objection from other legal : Yes/No heirs on stamp papers ( III ) Copy of Death Certificate : Yes/No :-Signature of the Applicant Dated FORM E Checklist for Reimbursement of Medical Claims (See sub-clause(3) of clause 12) Full Name of Card Holder Govt.Employee( In Block Letters) www.pranab.jiaganj.com 4/51 Name of the Govt. employee : 2 Employee Code No.(G.P.F.A/C No.) : 3 Designation : 4 Present Pay ( Basic Pay + Dearness Pay): 5 Entitlement of Accommodation : 6 Date of Birth : 7 Date of Superannuation : 8 Residential Address : 9 Details of Falily : Sl.No Age 12345 Shri/Smt…………………………………………………………attached to……………………………………………………….. (Office) under ………………………………………………………………..Department has been enrolled under the West Bengal Health Scheme, 2008 with effect from ……………………………….. He/She and his/her family members are entitled to the medical attendance and treatment in a Govt. Hospital/enlisted Pvt.Hospital or Institution etc. in the entitled class mentioned in Sl. No. 5. This permit is valid for 6(six) months from the date issue. Signature of Cadre Controlling Authority/Head of the Office Monthly Income,if any Relationship FORM -F Temporary Family Permit [ See sub-clause(9) of clause 10] Name www.pranab.jiaganj.com 5/5