Central govt employees Medical reimbursement Form

CENTRAL GOVERNMENT HEALTH SCHEME
CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS
1. CGHS Token No. and place of issue :
2. Validity of CGH Card (For pensioners)& : from…………to………….
Entitlement : Pvt. / Semi Pvt./General
3. Full name of Card Holder (Block Letters) :
4. Status (Govt. Servant/Pensioner/Other) :
5. The following documents are submitted :
{Please tick (-/) the relevant column}
(a) Medical 2004 Form : Yes/No
(b) Photocopy of CGHS card : Yes/No.
(c) Essentiality Certificate : Yes/No
(d) No. of Original Bills : …………
(e) Whether original bills/vouchers : Yes/No.
have been verified
(f) Copy of discharge summary : Yes/No.
(g) Copy of Permission letter : Yes/No.
(h) Whether the hospital has given breakup : Yes/No.
for lab investigations
(i) Original papers have been lost the
following documents are submitted—
I. Photocopies of claim papers : Yes/No
II. Affidavit on Stamp Paper : Yes/No.
(j) Incase of death of card holder the
following documents are submitted----
I. Affidavit on Stamp paper by
Claimant : Yes/No.
II. No objection from other legal
Heirs on Stamp papers : Yes/No.


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