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MRC-Form-for-Pensioners-20200910161048 (1)

The document is a Medical Reimbursement Claim Form for pensioner beneficiaries under the Central Government Health Scheme (CGHS). It requires detailed information about the principal card holder, patient, treatment, and associated costs, along with necessary declarations and supporting documents. Additionally, it outlines the procedures for claims, including affidavits for lost documents and claims in case of the card holder's death.

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61 views5 pages

MRC-Form-for-Pensioners-20200910161048 (1)

The document is a Medical Reimbursement Claim Form for pensioner beneficiaries under the Central Government Health Scheme (CGHS). It requires detailed information about the principal card holder, patient, treatment, and associated costs, along with necessary declarations and supporting documents. Additionally, it outlines the procedures for claims, including affidavits for lost documents and claims in case of the card holder's death.

Uploaded by

praveenconsultations
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FORM - MRC (P)

(For pensioner beneficiaries)


CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL REIMBURSEMENT CLAIM FORM
(To be filled by the Principal Card holder/Claimant in BLOCK LETTERS)

1. (a) Name of the Principal CGHS Card Holder


(b) CGHS Ben ID No.
(c) CGHS Wellness Center to which the card is attached :
(d) Validity of CGHS Card
(e) Ward Entitlement - Pvt./Semi-Pvt./General
(f) Full Address

(g) Mobile telephone No. and e-mail address, if any


2. (a) Patient's Name
(b) Patient's CGHS Ben ID No.
(c) Relationship with the Principal CGHS card holder

3. Category of pensioner beneficiary - please specify


(Central Govt. Pensioner/Pensioner of Autonomous/Statutory body/Ex- MP/ Ex-Governor/ Former
Judge of Supreme Court/ Former Judge of High Court/Freedom Fighter/Legal Heir/Others)

4. Name & address of the hospital / diagnostic center I


imaging center where treatment is taken or tests done:

5. Whether the hospital/diagnostic/imaging center is


empanelled under CGHS Yes/No

6. Treatment for which reimbursement claimed


(a) OPD/Test & investigations
(b) Indoor Treatment
7. Whether credit facility was availed. If not,
reasons thereof (clarification may be attached)

8. Whether treatment was taken in emergency Yes/No

9. Whether prior permission was taken for the treatment


Yes/No

10. Whether subscribing to any health/medical Yes/No


insurance scheme, If yes, amount claimed/received
11. Total amount claimed
(a) OPD Treatment
(b) Indoor Treatment
(c) Tests/Investigation

12.
Name of the Bank :............................................. SB Ale No.: ........................................................
Branch MICR Code: ........................................... IFSC Code.....................................................

DECLARATION
I hereby declare that the 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 dependent on me. I am a CGHS beneficiary and
the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the
rules.

Date: ........................................
Place: ....................................... Signature of the Principal CGHS card holder/ Claimant
Documents to be attached

1. Photo copy of the CGHS card of the principal card holder along with the patient's CGHS Card.
2. Copy of permission letter, if any.
3. Emergency certificate (original), in case of emergency.
4. Copy of the discharge summary.
5. Ambulance Certificate (original), if any.
6. Original bills /cash memo / vouchers etc. for the reimbursement amount claimed.

IMPORTANT

Kindly ensure to provide the following information I documents, wherever applicable:

a) Obtain Break up of Investigations from the hospital/diagnostic center/imaging center (details and rates of
individual tests and the exact number of tests, X-ray films, etc.,) as the reimbursable amount is calculated as
per approved rates per test.

b) In case of loss of original papers, Affidavits as per Annexure I to be submitted. All photocopies of the bills to be
attested by the treating doctor/specialist.

c) In case of death of the card holder, Affidavit as per Annexure II to be filled and attached to claim
reimbursement,

c) In case of implants, Invoice No. along with sticker with serial number of the implant to be attached.

d) In case of Coronary Stents, outer pouch of stents is to be enclosed.

e) In case of replacement of pacemaker/ ICD etc., copy of the warranty certificate of earlier pacemaker /ICD may
be enclosed.

Note: Misuse of CGHS facilities is a criminal offence. Penal action including cancellation of CGHS card may be taken
in case of willful suppression of facts or submission of false claims I statements.
Annexure-1

Draft for Affidavit for Duplicate Claim Papers/bills on stamp Paper

I, .................................... son / wife / daughter of................................................and resident of


.....................................................................................have lost / misplaced the original paper or
the same are not traceable. I hereby give an undertaking that I have not received any payment
against the original bills/claim papers from any source and that if the original papers are traced, I
shall not stake claim against original bills in future and that in the event, I receive any cheque
against the original bills in future, I shall return the same to competent authority.

Deponent

Verified by Notary Public


Annexure - II

Draft for Affidavit on Stamp Paper for claiming medical reimbursement


IN CASE OF DEATH of a CGHS Card Holder

I,...........................husband I wife/ son/ daughter of Late......................................and


resident of ................................................................., hereby submit the medical
reimbursement claim papers pertaining to treatment of my husband / wife / father /
mother Late Shri/ Smt............................who has expired on .......................... (copy of
Death Certificate is enclosed).

Late Shri/Smt..................................has left behind the following other legal heirs,


none of whom have any objection if the entire reimbursable amount is paid to me.

No Objection Certificate signed by other legal heirs on Stamp paper is enclosed.

Deponent

Attested by Notary Public

Draft for No Objection Certificate on Stamp Paper.

We (i)............................................ S/o 0/o Late Shri.........................................


(ii). ........................................... S/o 0/o Late Shri.........................................
(iii). ................................................. S/o D/o Late Shri..........................................
(--) ..........................................................................................................
(--) ..........................................................................................................
(--) ..........................................................................................................
being the legal heirs of Late Shri/Smt.....................................have no objection if the
entire amount reimbursable pertaining to the treatment of late Shri / Smt
.............................................................is paid to Shri / Smt .............................................

(i) (Signature) (ii) ( Signature ) (iii) (Signature)


Name: Name • Name:
Address: Address: Address

(iv)........................... (v)........................... (vi).........................

Verified by Notary Public

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