(Reimbursement Form – INDOOR – NON REFD.

To,
The ______________________________,
_________________________ Hospital,
Eastern Railway,
______________________.

Sir/Madam,

Reimbursement of medical expenses incurred by _________________________________

____________________ kindly arrange to reimburse the medical expenses incurred by _____________
_______________________________________ of Rs. _____________ (Rupees ___________________
____________________________________________ for doing treatment (_______________________
___________________________ ) at _____________________________ .
In this connection I hereby submit my application with all relevant papers for your kind
perusal and necessary action please.
Thanking you,
Yours faithfully,
Dated:
DA: Papers containing _______ Pages.
___________________________
(Signature of applicant)
Name:
Designation:
Phone No.

1. GR-3 Forms-2 copies, duly filled up & signed by the applicant and forwarded by departmental
Officer (for employee) At Page ________.
2. Essentiality Certificate-“A”-02 Nos. &-“B”-02 Nos. for Indoor patient (At Page ________).
3. Original MD/PCMD’s Permission letter with photocopy (At Page ________).
4. Original bill with photocopy, duly signed by treating doctor (At Page ________).
5. Photocopy of Medical Identity Card duly attested by Gazetted officer (At Page ________).
6. Photocopy of related Medical Test/Investigation duly attested by Gazetted officer
(At Page ____________).
7. 01(One) photocopy of Bank cheque leaf.
8. Declaration-Not received any money from any medical insurance company towards this bill.
9. Mandate Form duly signed from Bank.
 REIMBURSEMENT CLAIM FORM

I) 1. of the Railway/Retd: Employee _____________________________________________________

(In block letters)
2. Designation of the Railway/Retd: Employee ____________________________________________
(In block letters)
3. Office & station of employment ______________________________________________________
4. Pay/Last pay of the Railway/Refd. Employee including grade pay ___________________________
5. Residential address ________________________________________________________________
6. MIC/RELHS No. and issuing authority _________________________________________________
7. MIC/RELHS registered at H.Unit/Hospital ______________________________________________
II) (a) Name & Age of the patient ________________________________________________________
(b) Patient’s relationship to the Rly/Retd. Employee _______________________________________
III) Details of Indoor treatment at Non Railway Institute:
a. Name of the Hospital __________________________________________________________
b. Date of admission ____________________________________________________________
c. Date of discharge _____________________________________________________________
d. Diagnosis ___________________________________________________________________
e. Amount of total Hospital bill (attach details bill) _____________________________________
f. Whether treatment was taken in emergency _______________________________________
g. Are you CTSE member (Y/N) ____________________________________________________
IV) Whether subscribing to any Health Insurance Policy or covered under any other health scheme. If
yes, have you received any amount from Insurance company for the treatment in question. Give
details if any on separate sheet of paper.
V) Total amount claimed ______________________________________________________________
VI) Details of bank account where reimbursement amount to be paid.
a. Name of the bank ______________________________ b. Account No. ____________________
c. Branch MICR code __________________________ d. IFSC Code _________________________
VII) List of enclosure [Please tick (√) the documents attached and write additional documents]
a. Photocopy of MIC/RELHS card.
b. Essentially cum emergency certificate by the Non Rly.Hospital.
c. Discharge Summary.
d. Original bills of Hopital.
e. Original cash vouchers of drugs/consumables/inplants etc. if any.
f. Other pouch Stent, pacemaker, implants etc.
g. Any other enclosures __________________________________________________________
(In case of many enclosures, write number of additional enclosure here and attach a separate
sheet with details).
 DECLARATION TO BE SIGNED BY THE RAILWAY EMPLOYEE

I hereby declare that the statement in this application are true to the best of my knowledge and
belief and that the person for whom medical expenses were incurred is wholly dependent upon me. I
am aware that misuse of medical facilities or misrepresentation of any kind can attract penal action
including cancellation of MIC/RELHS card. I hereby declare that this is my final claim and I shall not
make any claim in future to Rly. Or any health scheme in respect to this treatment episode.

Date:
____________________________________
Place: _______________ Signature of the Railway employee

 In case the beneficiary has medical insurance policy and intend to make claim for the
treatment in question then he/she may make claim to insurance company first and then
submit claim to Rly. With documents; bills etc attested by insurance company.

Eastern Railway
Medical Department

ESSENTIALITY cum EMERGENCY CERTIFICATE

I certify that Shri/Shrimati/Kumar/Kumari __________________________________________________

Dependent relative of Shri/Shrimati _____________________________________________ employed in
Indian Railway as _____________________________________ has been under treatment for ________
_______________________________________________ disease from ____________to ____________
at the ____________________________________ hospital and that the treatment as described in the
attached Discharge Card No. ________________________________ and attached bills hereon were
provided due to an emergency situation treatment for which could not have been delayed. I further
certify that the treatment provided was essentially required.

_________________________________________
Signature of the Medical Officer In charge of
the case at the Non Railway hospital with
name and stamp/seal

___________________________________________
Signature of Hospital In charge or Authorized
signatory with stamp/seal
Forwarded to the Principal Chief Medical Director together with the enclosures for arranging
reimbursement as admissible.

Place:
Date: Head of Department/Divisional/District Officer
____________________________________________________________________________________

Transmitted to PFA&CAO __________________ Railway Sanction is accorded to the refund of

Rs._______________ (Rupees _______________________________________________________ vide
coloumns _____________________________ chargeable to

Rs. _____________ to ______________ Rs. ____________ to _____________________

Rs. _____________ to ______________ Rs. ____________ to _____________________

A Pay order for the amount drawn in favour of the employee is enclosed to enable him/her to arrange
payment (Enclo)

No.

Date: ________________________________________
Principal Chief Medical Director

Note:
This application form shall be prepared in duplicate by the employee and the department will forward
both copies to:
PCMD who will after sanctioning reimbursement, send the original copy to PFA&CAO. All records for the
amount paid to hospital etc.by column 9 should invariably be submitted along with this application. If
the details of charges (daily train, pinfold of stay etc_) have not been furnished in the receipts a
separate certificate showing the allocation of charges should be submitted to ____________________
for verification of the amount claimed.
If the treatment was received at a hospital other than Govt. hospital, specified in the annexure to rule
919.11 certificate to the effect that the treatment at that hospital was availed or at the instance of the
authorized medical attendant should be submitted to enable the PCMD to consider the application for
reimbursement, essentiality certificate in the prescribed form which can be obtained along with this
form, the Department should submit in respect of special medicines purchased.
A certificate from the medical officer treating the patient to the effect that the disease of the patient was
not one which should be attributed to his/her intemperate habits or conducts should be submitted
without which the application for reimbursement will not be considered.
Reimbursement charges paid to Non-Rly Hospital in respect of families of class IV employees is not
admissible.
Workshop staff one scale of pay the maximum of which is Rs.60 and below will be treated in the same
way as class IV staff as purpose of reimbursement of medical charges under the rules.

N.B. Separate form should be used for each patient.

Recorded parameters to establish the emergency admission
(to be filled in and signed by the treating doctor of the hospital with seal)

A Admission Details.

1. Date and time admission.

2. Admitted through OPO service/emergency service.
3. Admitted to an ICU bed or general bed or cabin bed.

B. Clinical findings at the time of admission. Following findings should be made available and
critically evaluated.
Pulse Rate

BP

Level of Consciousness

Any Convulsive feature

Urine Report

Ant other feature of shock

Body Temperature

Extent of external wound

Extent of active bleeding

Extent of Chest pain or

Pain in other part(s) of the body

C. Types of medical treatment given immediately after admission : –

1. List of emergency medicines given immediately after admission : –

________________________________________

2. Type of surgical procedure done immediately after admission.

_________________________________________
Seal & Signature of treating doctor
 NATIONAL ELECTRONICS FUND TRANSFER (NEFT)
MANDATE FORM FOR RAILWAY EMPLOYEES FOR DIRECT CREDIT TO BANK

1. EMPLOYEE’S NAME :

A) DESIGNATION :

B) DEPARTMENT :

C) BILL UNIT NO. :

D) EMP NO. :

E) RELHS NO. :
(In case of retired employee)

2. PARTICULARS OF BANK ACCOUNT.

A) BANK NAME :

B) BRANCH NAME :

C) IFSC CODE :

D) MICR CODE :

E) S. B. A/C. NO. :

F) COPY OF CHEQUE :

DA: One Photocopy of Bank cheque leaf.

I HEREBY DECLARE THAT THE PARTICULARS GIVEN ABOVE ARE CORRECT

AND COMPLETE.

SIGNATURE OF THE CUSTOMER

Phone No.
 MANDATE FORM – ECS/EFT

1. Details of Employee/Customer.

a) Address:

b) Contract Telephone No., E-mail address (if any):

2. PARTICULARS OF BANK ACCOUNT:

A) NAME of the Bank :

B) BRANCH NAME & Address :

C) Branch Telephone/Fax No. :

D) Bank Account No. :

E) Type of Account :

F) 9-digit MICR code of the Bank :

G) IFSC Code (For RTGS A/C) :

3. Date of effect:
I hereby declare that the particulars give above are correct and complete. If transaction
is delayed or not affected at all for reasons of incomplete or incorrect information – I
would not hold Eastern Railway responsible. I have understood the proposal and agree
to discharge the responsibility expected of me as a participant under scheme.

Date:

Signature of the Employee/Customer

Certified that the particulars furnished above are correct as per our record.

Bank Authority’s signature with stamp.

Note: Please attach a photocopy of blank cheque for verification of the bank particulars.
 (Reimbursement Form – OUTDOOR – REFD.)

To,
The ______________________________,
_________________________ Hospital,
Eastern Railway,
______________________.

Sir/Madam,

Reimbursement of medical expenses incurred by _________________________________

____________________ kindly arrange to reimburse the medical expenses incurred by _____________
_______________________________________ of Rs. _____________ (Rupees ___________________
____________________________________________ for doing treatment (_______________________
___________________________ ) at _____________________________ .
In this connection I hereby submit my application with all relevant papers for your kind
perusal and necessary action please.
Thanking you,
Yours faithfully,
Dated:
DA: Papers containing _______ Pages.
___________________________
(Signature of applicant)
Name:
Designation:
Phone No.

1. GR-3 Forms-2 copies, duly filled up & signed by the applicant and forwarded by departmental
Officer (for employee) At Page ________.
2. Essentiality Certificate-“A”-02 Nos. &-“B”-02 Nos. for Indoor patient (At Page ________).
3. Original MD/PCMD’s Permission letter with photocopy (At Page ________).
4. Original bill with photocopy, duly signed by treating doctor (At Page ________).
5. Photocopy of Medical Identity Card duly attested by Gazetted officer (At Page ________).
6. Photocopy of related Medical Test/Investigation duly attested by Gazetted officer
(At Page ____________).
7. 01(One) photocopy of Bank cheque leaf.
8. Declaration-Not received any money from any medical insurance company towards this bill.
9. Mandate Form duly signed from Bank.
 (IRMM 2000, See Para 653 & Annexure IV)
REIMBURSEMENT CLAIM FORM

FORM OF APPLICATION TO BE SUBMITTED BY A RAILWAY EMPLOYEE FOR CLAIMING REIMBURSEMENT

OF MEDICAL EXPENSES
(Note: Separate form should be used for each patient)

I) 1. of the Railway/Retd: Employee ___________________________________________________

(In block letters)
2. Designation of the Railway/Retd: Employee ___________________________________________
(In block letters)
3. Office & station of employment _____________________________________________________
4. Pay/Last pay of the Railway/Refd. Employee including grade pay __________________________
5. Residential address ______________________________________________________________
6. MIC/RELHS No. and issuing authority ________________________________________________
7. MIC/RELHS registered at H.Unit/Hospital _____________________________________________
II) (a) Name & Age of the patient _____________________________________________________
(b) Patient’s relationship to the Rly/Retd. Employee _____________________________________
III) Details of Indoor treatment at Non Railway Institute:
a. Name of the Hospital __________________________________________________________
b. Date of admission ____________________________________________________________
c. Date of discharge _____________________________________________________________
d. Diagnosis ___________________________________________________________________
e. Amount of total Hospital bill (attach details bill) _____________________________________
f. Whether treatment was taken in emergency _______________________________________
g. Are you CTSE member (Y/N) ____________________________________________________
IV) Whether subscribing to any Health Insurance Policy or covered under any other health scheme. If
yes, have you received any amount from Insurance company for the treatment in question. Give
details if any on separate sheet of paper.
V) Total amount claimed ______________________________________________________________
VI) Details of bank account where reimbursement amount to be paid.
a. Name of the bank ______________________________ b. Account No. ____________________
c. Branch MICR code __________________________ d. IFSC Code _________________________
VII) List of enclosure [Please tick (√) the documents attached and write additional documents]
a. Photocopy of MIC/RELHS card.
b. Essentially cum emergency certificate by the Non Rly.Hospital.
c. Discharge Summary.
d. Original bills of Hopital.
e. Original cash vouchers of drugs/consumables/inplants etc. if any.
f. Other pouch Stent, pacemaker, implants etc.
g. Any other enclosures __________________________________________________________
(In case of many enclosures, write number of additional enclosure here and attach a separate
sheet with details).
 DECLARATION TO BE SIGNED BY THE RAILWAY EMPLOYEE

I hereby declare that the statement in this application are true to the best of my knowledge and
belief and that the person for whom medical expenses were incurred is wholly dependent upon me. I
am aware that misuse of medical facilities or misrepresentation of any kind can attract penal action
including cancellation of MIC/RELHS card. I hereby declare that this is my final claim and I shall not
make any claim in future to Rly. Or any health scheme in respect to this treatment episode.

Date:
____________________________________
Place: _______________ Signature of the Railway employee

 In case the beneficiary has medical insurance policy and intend to make claim for the
treatment in question then he/she may make claim to insurance company first and then
submit claim to Rly. With documents; bills etc attested by insurance company.

Eastern Railway
Medical Department

ESSENTIALITY cum EMERGENCY CERTIFICATE

I certify that Shri/Shrimati/Kumar/Kumari __________________________________________________

Dependent relative of Shri/Shrimati _____________________________________________ employed in
Indian Railway as _____________________________________ has been under treatment for ________
_______________________________________________ disease from ____________to ____________
at the ____________________________________ hospital and that the treatment as described in the
attached Discharge Card No. ________________________________ and attached bills hereon were
provided due to an emergency situation treatment for which could not have been delayed. I further
certify that the treatment provided was essentially required.

_________________________________________
Signature of the Medical Officer In charge of
the case at the Non Railway hospital with
name and stamp/seal

___________________________________________
Signature of Hospital In charge or Authorized
signatory with stamp/seal
Forwarded to the Principal Chief Medical Director together with the enclosures for arranging
reimbursement as admissible.

Place:
Date: Head of Department/Divisional/District Officer
____________________________________________________________________________________

Transmitted to PFA&CAO __________________ Railway Sanction is accorded to the refund of

Rs._______________ (Rupees _______________________________________________________ vide
coloumns _____________________________ chargeable to

Rs. _____________ to ______________ Rs. ____________ to _____________________

Rs. _____________ to ______________ Rs. ____________ to _____________________

A Pay order for the amount drawn in favour of the employee is enclosed to enable him/her to arrange
payment (Enclo)

No.

Date: ________________________________________
Principal Chief Medical Director

Note:
This application form shall be prepared in duplicate by the employee and the department will forward
both copies to:
PCMD who will after sanctioning reimbursement, send the original copy to PFA&CAO. All records for the
amount paid to hospital etc.by column 9 should invariably be submitted along with this application. If
the details of charges (daily train, pinfold of stay etc_) have not been furnished in the receipts a
separate certificate showing the allocation of charges should be submitted to ____________________
for verification of the amount claimed.
If the treatment was received at a hospital other than Govt. hospital, specified in the annexure to rule
919.11 certificate to the effect that the treatment at that hospital was availed or at the instance of the
authorized medical attendant should be submitted to enable the PCMD to consider the application for
reimbursement, essentiality certificate in the prescribed form which can be obtained along with this
form, the Department should submit in respect of special medicines purchased.
A certificate from the medical officer treating the patient to the effect that the disease of the patient was
not one which should be attributed to his/her intemperate habits or conducts should be submitted
without which the application for reimbursement will not be considered.
Reimbursement charges paid to Non-Rly Hospital in respect of families of class IV employees is not
admissible.
Workshop staff one scale of pay the maximum of which is Rs.60 and below will be treated in the same
way as class IV staff as purpose of reimbursement of medical charges under the rules.

N.B. Separate form should be used for each patient.

CERTIFICATE TO BE OBTAINED FROM AN ATTENDING NON-RAILWAY INSTITUTE FOR
CLAIMING REIMBURSEMENT OF MEDICAL EXPENSES
CERTIFICATE “A”
(To be completed in the case of patient who os NOT ADMITTED to Hospital for treatment)
1. Name and designation of the
Railway Employee (in block letters) :__________________________________________
2. Office in which employed : _________________________________________
3. Pay of the Railway Employee : _________________________________________
4. Place of Duty : _________________________________________
5. Actual Residential Address : _________________________________________
_________________________________________
_________________________________________
6. Name of the patient and his/her : _________________________________________
7. Relation with the Rly. Employee : _________________________________________
(Note: in the cae of children, state age also)

8. Place at which the patient feel ill : _________________________________________

9. Nature of illness and its duration : _________________________________________
I Dr. ______________________________________ hereby certify: –
(a) That the injections administered were for immunizing for prophylactic purpose
(b) That the patient has been under treatment
At ______________________________________________________ hospital.
Dispensary and that the under mentioned medicines prescribed by me in this connection were
essential for the recovery/prevention of serious deterioration the condition of the patient. The
medicines are not stocked in the ___________________________________________ (Name of the
hospital/dispensary) for supply to private patient and do not include proprietary preparation for
which cheaper substances of equal therapeutic value are available nor preparations which are
primarily foods, toilet disinfectants.
Name of Medicines Price
1. ________________________________________________ ____________
2. ________________________________________________ ____________
3. ________________________________________________ ____________
4. ________________________________________________ _____________
5. ________________________________________________ _____________
c) That the patient is/was suffering from __________________ and is/was under my treatment
from _____________ to ______________
d) That the patient was given pre-natal or post=natal treatment.
e) That the X-ray,laboratory test etc for which an expenditure of Rs. _________________ was
incurred were necessary and were undertaken on my advice at _________________________
(Name of the hospital/Laboratory).
f) That I referred the patient to Dr. ______________________________ for specialist/Consultation
and that the necessary approval of the _______________________________________________
(Name of the Principal Medical Officer) as required under the rules was obtained.
g) That the patient did not require hospitalization.

________________________________________
Signature and designation of the Medical Officer
Name of the hospital/Dispensary to whom attached
 NATIONAL ELECTRONICS FUND TRANSFER (NEFT)
MANDATE FORM FOR RAILWAY EMPLOYEES FOR DIRECT CREDIT TO BANK

1. EMPLOYEE’S NAME :

A) DESIGNATION :

B) DEPARTMENT :

C) BILL UNIT NO. :

D) EMP NO. :

E) RELHS NO. :
(In case of retired employee)

2. PARTICULARS OF BANK ACCOUNT.

A) BANK NAME :

B) BRANCH NAME :

C) IFSC CODE :

D) MICR CODE :

E) S. B. A/C. NO. :

F) COPY OF CHEQUE :

DA: One Photocopy of Bank cheque leaf.

I HEREBY DECLARE THAT THE PARTICULARS GIVEN ABOVE ARE CORRECT

AND COMPLETE.

SIGNATURE OF THE CUSTOMER

Phone No.
 MANDATE FORM – ECS/EFT

1. Details of Employee/Customer.

a) Address:

b) Contract Telephone No., E-mail address (if any):

2. PARTICULARS OF BANK ACCOUNT:

A) NAME of the Bank :

B) BRANCH NAME & Address :

C) Branch Telephone/Fax No. :

D) Bank Account No. :

E) Type of Account :

F) 9-digit MICR code of the Bank :

G) IFSC Code (For RTGS A/C) :

3. Date of effect:
I hereby declare that the particulars give above are correct and complete. If transaction
is delayed or not affected at all for reasons of incomplete or incorrect information – I
would not hold Eastern Railway responsible. I have understood the proposal and agree
to discharge the responsibility expected of me as a participant under scheme.

Date:

Signature of the Employee/Customer

Certified that the particulars furnished above are correct as per our record.

Bank Authority’s signature with stamp.

Note: Please attach a photocopy of blank cheque for verification of the bank particulars.