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Atal Amrit Abhiyan Application Format

This document appears to be an application form for the Atal Amrit Abhiyan, a pioneering statewide health assurance scheme run by the Department of Health & Family Welfare of the Assam government. The multi-page form requests information such as the patient's name, age, gender, address, annual family income, disease requiring treatment, and hospital where treatment was received. It lists the types of documents required to be submitted along with the application, including a photograph of the patient, income certificate, ID documentation, medical referral/discharge documents, and original bills. Completed applications are to be submitted in person or by post to the joint director of health services for the concerned district.

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Bijit Singha
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101 views2 pages

Atal Amrit Abhiyan Application Format

This document appears to be an application form for the Atal Amrit Abhiyan, a pioneering statewide health assurance scheme run by the Department of Health & Family Welfare of the Assam government. The multi-page form requests information such as the patient's name, age, gender, address, annual family income, disease requiring treatment, and hospital where treatment was received. It lists the types of documents required to be submitted along with the application, including a photograph of the patient, income certificate, ID documentation, medical referral/discharge documents, and original bills. Completed applications are to be submitted in person or by post to the joint director of health services for the concerned district.

Uploaded by

Bijit Singha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Atal Amrit Abhiyan Please affix

photograph of the
(A Pioneering State wide Health Assurance Scheme) patient
(Attested by
Department of Health & Family Welfare Doctor)
Government of Assam
Manual Application Form *
1. Name of the Patient :
(in Block Letters)

2. Age :

3. Gender :

4. Father’s/Guardian’s :
Name
5. Permanent address : House No:
Village:

Post Office:
Police Station:
District:
Pin Code:

6. Present Address : House No:


Village:

Post Office:
Police Station:
District:
Pin Code:

7. Mobile Number :

8. Annual Income of the : Rs.


Family

* This application form is valid till 31st March 2017.

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9. If the Application is not : Name of the Applicant:
submitted by the patient
Relationship with the patient:
Address:

Contact No:
10. Disease for which :
Cardiovascular disease Cancer
Treatment is required
(Please tick √in the
appropriate box) Kidney Diseases Neo Natal Diseases
(Only 436 procedures of
these disease groups shall Neurological Conditions Burns
be applicable)
11. Name of Hospital where :
the treatment received
12. Total cost incurred in the : Rs.
treatment

Declaration
I declare that the information and documents given are correct and complete in all
respects and that I have not claimed the same amount from any other Scheme/Insurance.

Date: Signature of the Applicant/Patient

Documents to be submitted along with the application


Please tick √
1. Photograph of the Patient (Attested by Doctor) □
2. Annual Income Certificate issued by Circle Officer
(Attested copy of the certificate to be enclosed along with the □
application)
3. Attested copy of the Voter ID or Voter ID of Parent □
4. Attested copy of the Referral Certificate/ Discharge certificate &
□
Prescription from the hospital
5. Original copy of the Bills attested by the treating hospital
□
(Only empanelled hospital under Assam Arogya Nidhi)

The Filled in application form is to be submitted, by hand or by post, to the Office of


the Joint Director of Health Services of the concerned district.

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