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ANNEXURE-I
DELHI GOVERNMENT EMPLOYEES HEALTH SCHEME
MODIFIED CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS
1.
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—
2.
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IN SERVICE
3.General
4.—5.—
6. The following documents are Attached (Please tick the relevant column)
| (a) | Revised Medical Form - 2004 | |
| (b) | Photocopy of DGEHS card showing validity | |
| (c) | Photocopy of referral/authorization form from AMA | |
| (d) | Original Bills | |
| (e) | Copy of prescription for OPD cases / discharge summary for indoor | |
| (f) | Breakup for lab investigation | |
| (g) | Breakup of drugs prescribed | |
| (h) | Emergency certificate from hospital empanelled/registered with Government | |
| (i) | Self explanatory letter showing the need of emergency visit | |
| (j) | Non-availability certificate from AMA for drugs prescribed in OPDs | |
| (k) | If original papers have been lost — photocopies of claim papers and affidavit on Stamp Paper | |
| (l) | In case of death of card holder — claimant affidavit, legal heirs' NOC and death certificate |
7. IFSC Code—
Name of Bank—
Branch address—
A/c No.—
MICR Code—
Dated: —Signature of DGEHS card holder
(R) —
(R) —
Note:
1. Kindly enclose photocopy of cancelled cheque for online transfer of money to the account of beneficiary.
2. Provide one original copy and two photocopies of complete set of claim.
1. Kindly enclose photocopy of cancelled cheque for online transfer of money to the account of beneficiary.
2. Provide one original copy and two photocopies of complete set of claim.
ANNEXURE-II
DELHI GOVERNMENT EMPLOYEES HEALTH SCHEME
REVISED MEDICAL 2004 FORM FOR REIMBURSEMENT OF MEDICAL CLAIMS
(To be filled by the claimant)
1.
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2.
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IN SERVICE
3.General
4.—
5.—
6.—
7.—
8.Bank—Branch—
A/c—MICR—IFSC—
9.
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—
10.—
11.—
12. TOTAL AMOUNT CLAIMED
| Treatment Type | Consultation | Investigation | Medicine | Other Charges |
|---|---|---|---|---|
| For OPD Treatment | ₹ 0.00 | ₹ 0.00 | ₹ 0.00 | ₹ 0.00 |
| For Indoor Treatment | ₹ 0.00 | ₹ 0.00 | ₹ 0.00 | ₹ 0.00 |
13.NA
14.NIL
DECLARATION:
I hereby declare that statements 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 dependant on me. I am a DGEHS beneficiary and the DGEHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules.
Dated: —Signature of DGEHS card holder
Note: Misuse of DGEHS facilities is a criminal offence. Suitable action including cancellation of DGEHS Card shall be taken in case of willful suppression of facts or submission of false statements. Suitable disciplinary action shall be taken in case of serving employees.
MEDICAL REIMBURSEMENT BILL IN R/O —
DESIGNATION — —
CALCULATION SHEET
| Sr | Bill No. | Date | Patient Name | Treatment Category | Amount | Hospital/Store | |
|---|---|---|---|---|---|---|---|
| 01 | — | — | — | — | — | — |
TOTAL AMOUNT CLAIMED (IN FIGURES): ₹ 0.00
TOTAL AMOUNT CLAIMED (in words): ZERO RUPEES ONLY
TOTAL AMOUNT CLAIMED (in words): ZERO RUPEES ONLY
1. I certify that the patient whom the medical reimbursement claim has been made in the bill is/are wholly dependent upon me.
2. I certify that my wife/husband is not employed in Govt./Semi-Govt. service & he/she has not submitted any claim for the purpose.
3. I certify that Super Bazar or any other co-operative drug store is not less than two kilometer away from the residence.
2. I certify that my wife/husband is not employed in Govt./Semi-Govt. service & he/she has not submitted any claim for the purpose.
3. I certify that Super Bazar or any other co-operative drug store is not less than two kilometer away from the residence.
APPLICANT SIGNATURE
DDO
HOS
ACCOUNT OFFICER