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    Form DGHS

    Uploaded by

    VIKAS KOCHAR

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Form DGHS

    Uploaded by

    VIKAS KOCHAR
    139 views4 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    139 views4 pages

    Form DGHS

    Uploaded by

    VIKAS KOCHAR

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    INDEX CARD

    Date of Superannuation ______________________

    Govt. of NCT of Delhi

    Health and Family Welfare Deptt.

    DELHI GOVT. HEALTH SCHEME

    1. Name of Govt. Employees :


    ________________________________________
    (In full and block letters)

    2. Deptt./Office in which employed : ________________________________________

    _____________________________________________________________________

    3. Residential Address : ________________________________________

    _____________________________________________________________________

    4. Nearest Delhi Govt. Dispensory/ Hospital : __________________________________

    ______________________________________________________________________

    5. Details of family members : ________________________________________

    Name Date of Relationshi Name Date of Relations


    Birth p Birth hip
    -2-

    I hereby declare that :-

    (a) My father / mother namely ________________________________________


    Is / are wholly / mainly dependent upon me and that he / she/ they normally
    residing with me in ____________________________________________ ____

    ___________________________________________. The total monthly income


    of my father / mother does not exceed my pay plus dearness pay (where
    applicable) and that it does not also exceed Rs. 500/- per month.

    (b) My son / brother ___________________________________________________


    age _________________ years is unemployed wholly dependent on me.

    © My daughter / sister ______________________________________________age


    years is unmarried / unemployed and wholly dependent on me.

    (c) I undertake to surrender the Identity Card on my leaving the Deptt./office on


    transfer / retirement / termination of service, resignation etc.

    Signature / Thumb Impression of Government Employee.

    Dispensary ___________________________________________________

    Signature / Thumb Impression of Government Employee.


    Date on which Identity Card Issued ____________________________________
    Certified that Index / Identity Cards has / have been scrutinized by the issuing
    Authority and correctly issued in accordance with the rules and orders issued by
    the Deptt. Of Health & Family Welfare.

    OFFICE STAMP SIGNATURE & DESIGNATION OF


    ISSUING AUTHORITY

    Cont. 3/-

    -3-

    PROFORMA FOR OPTION

    I, ____________________________________________, hereby opt the Scheme


    for providing medical facilities to the employees/ pensioners of Delhi Govt. w.e.f
    ________________________________.

    I do not opt the Scheme as my wife/husband is a member of C.G.H.S. She/ He


    will avail medical facilities under C.G.H.S. and he / she will get re-imbursement of
    Medical treatment in respect of family for special treatment.

    My wife / husband is employed / not employed in Govt. Department at


    _________________________________________________________. She/ He will not
    get the reimbursement of special treatment from her/his employer.

    The contribution @ Rs._________________p.m. may be deducted from my


    salary for the month of _______________ onwards.

    Signature ___________________________

    Name ___________________________
    ___________________________

    ___________________________

    Designation ___________________________

    Branch/Deptt. ___________________________

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