Scribd
Upload
344 views

Fixed Medical Allowance

This document is a revised undertaking form for pensioners and family pensioners to claim a fixed medical allowance of Rs. 1000 per month. It requires the pensioner to declare that they live over 2.5 km from the nearest railway hospital and will not avail of outpatient services at railway medical facilities. It also requires them to confirm they have not received any outpatient treatment for the period since their retirement or December 1, 1997, whichever is later. The pensioner must sign declaring the information is correct and acknowledging action could be taken if any information is found to be false.

Uploaded by

v.s.r.srikanth08
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
344 views

Fixed Medical Allowance

This document is a revised undertaking form for pensioners and family pensioners to claim a fixed medical allowance of Rs. 1000 per month. It requires the pensioner to declare that they live over 2.5 km from the nearest railway hospital and will not avail of outpatient services at railway medical facilities. It also requires them to confirm they have not received any outpatient treatment for the period since their retirement or December 1, 1997, whichever is later. The pensioner must sign declaring the information is correct and acknowledging action could be taken if any information is found to be false.

Uploaded by

v.s.r.srikanth08
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
You are on page 1/ 1

Annexure-I

Board’s letter No. PC-V/2016/A/Med/1 (FMA) dated 28.7.2017 [RBE No.75/2017]

REVISED UNDERTAKING FORM

(To be submitted in DUPLICATE by pensioners / family pensioners to the concerned Pension


Disbursing Authority (PDA) / Pension Sanctioning Authority (PSA), whichever is applicable.
PDA should retain one copy of the Undertaking and furnish the other to the PSA for
necessary action)

***

I__________________________________________, a retired employee / family pensioner whose


______________________ (specify relation of Family pensioner with deceased Railway employee)
was an employee of (Office address) _____________________ declare that I am residing at
(residential address indicated in PPO) ___________________________________ which is beyond 2.5
Kms from the nearest Railway Hospital / health unit ________________________ (name of the
Hospital / Health Unit as contained in Annexure III to Railway Board’s letter No. PC-V/98/I/7/1/1
dated 21.4.99).

2. Accordingly, I hereby opt to claim fixed medical allowance of Rs.1000/- per month as per
prescribed rate. Necessary endorsement may please be made in my PPO in this regard.
Simultaneously, I undertake that I will not avail of OPD facilities (except in cases of chronic diseases
as mentioned in Board’s letter No.2006/H/DC/JCM dated 12.10.2006) at Railway hospitals / health
units from the day I claim Medical Allowance. I also understand that grant of Medical Allowance is
subject to the terms and conditions specified in Board’s letters No.PC-V/98/I/7/1/1 dated 21.4.99 and
1.3.2004 and latest being letter No.PC-V/2006/A/Med/1 dated 15.09.2009.

3. I also declare that I have not availed of any treatment as Out Door Patient (except in cases of
chronic diseases as mentioned in Para-2 above) for the period from __________________________
(indicate here the date of retirement or the date of availing OPD facility on the last occasion or
1.12.1997, whichever is later) to this day _____________________ (indicate here the date on which
this declaration is signed). I may accordingly be paid arrear of Medical Allowance @ Rs.1000/- per
month for the period mentioned above as per prescribed rate. FMA Rs.1000/- from 01.07.2017

4. The above information furnished by me is correct to the best of my knowledge and belief. I also
understand that, if at any stage, it is found that the undertaking submitted by me is incorrect or
carries false information, my FMA is liable to be stopped with immediate effect and further suitable
action could be taken to recover the excess amount paid to me.

Signature _______________________

Name in full _____________________

PPO No_________________________

Issued by _______________________

SB A/C No ______________________

Post office/Bank __________________

Branch _________________________

Place __________________________

Date ___________________________

You might also like