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7(18)/20 14-Pers.I
Governmentof India
Department of Electronics & InformationTechnology
(Personnel- I Section)
Dated: 08.07.2014
CIRCULAR
Sub : Medical Claim 1Reimbursement - ree:.
Ministry of Health & Family Welfare has issued revised medical form for reimbursement,
titled as "Form MRC(S) - for Serving CGHS beneficiaries & Form MRC(P) - for Pensioner
CGHS beneficiaries form for Reimbursementof Medical Claim.
2. In the revised form, some essential information such as designation, employee code, inter
com no. etc. required to be furnished by the CGHSIAMA beneficiaries are missing, which is resulting
in delay in processing the medical claim in time bound manner.
3. It is therefore requested that all the CGHS1AMA beneficiaries of Deity to submit their claims
for reimbursement with enclosed format.
~
(Sandeep Kumar Ambasta)
SectionOfficer
To :
All staff 1Officers of the Department
Intra-dit
Department of Electronics & Information Technology
( Division)
Dated: ........
Sub : Reimbursement of Medical Claim - reg.
Sir /Madam,
Please find enclose herewith a medical claim containing bill/so Details
below in respect of Shri/Smt./Ku. namely ... .. .... .. ..... ... ... .. ..... for
Consultation/MedicineslTestiTreatment from lab/Hospital.
(Signature)
Name:
Design:
Emp.Code :
I.Com/Mobile No.:
SI.No. Bill No. Date Amount Consultation/T est/Medicines/Others
I
2
3
4
5
6
7
8
9
10
11
12
13.
14
15
16
17
18
19
20
TOTAL
(Rs.)
..
FORM-MRC(S)
(For .serving employees)
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICALREIMBUI3SEMENTCLAIM FORM
(To befiJledup.bythePrincipaICai'd holder!oBLOCKLETTERS)
,
1. (a) Name of the PrincipalCGHSCardHolder
(b) CGHSBen IDNo.
(c) Employee Code No.
(d) Ward EntillemEltlt .. Pvt.lSeml-PvtJGeneral
(e) FuUAddress
(f) Mobiletelephone No. and e..malladdress, Ifany
2. (a) Patlant's Name
(b) Patient's CGHS Ben IDNo.
(c) Rel;:itionshlpWiththe PrincipalCGHS<;anthol~et
3. Name &eddres$of the hosplJalI diagnosticcenter I
Imagingcenter where treatment Is teken or tests d(Jrie:
4. Whether the hospJtaIJdtagnosticlimaglng center Is
em panelled underCGHS
YesJNo
"
5. Treatmenffor whiChrelmbtu'llementdalmed
(8) OPD Treatment ITest &investigations
(b) Indoor Treatment
6.
Whether treatment was taken In8m$rgency
YesINo
7.
Whether prior' permission wastak.en for the treatment :
Yas!No
8.
Whethersubsaiblng to any health/medicat \n$ulC!Oce
~ema. Iryes, amount claimed/received
YesINo
9. Details of MedicalAdvance,tPken,ihl'lY
10. Total.amount claimed
(a) OPD Treatment
(b) Indoor Treatmerit
(c) Testsllnvestigatlon
11. Name of the Bani<: ..............
Branch MICR.Code: ............................................
sa NcNo.: i ..............................
IFSCCode ............
DECLARATION .
I hereby declare that the statements. made IrttheappUt:allon ate true to the best of my knowledge and belief
snothe penlon for whommedicalexpenses were Incurred Is wholly dependent on me. I am a CGHS beneficiary
and the CGHS card Wasvalid atthe time oftreatment.J agree. for the reimbursement S$ is admissible underthe
rules. .
Date: .............................
Place: Signatureofthe PrincipalCGHScardholder