Job 3448 3920 1
Job 3448 3920 1
Job 3448 3920 1
Form of application for claiming refund of medical expenses incurred in connection with medical
attendance and/ or treatment of National Health Mission (NHM), Assam Employees and their families
for medical attendance/treatment taken from an Authorized Medical Attendant/ Hospital.
(NB: SEPARATE FORM SHOULD BE USED FOR EACH PATIENT)
1. EMPLOYEE DETAILS:
HRMIS ID :
Designation :
Present Address :
Permanent Address :
Mobile No. :
2. PATIENT INFORMATION:
Medical Problem :
Whether the patient a Govt./ Retired Govt. employee ( tick mark) : (Yes / No)
(If Yes, Office/ Division in which employed)
3. CLAIM DETAILS:
Whether the Patient covered under AAA/ PMJAY? ( tick mark) (Yes / No)
If Yes, Registration No. :
Whether any Medical Reimbursement Claim submitted in the current Financial Year? ( tick mark)
(Yes / No)
4. MEDICAL ATTENDANCE:
(i) Accommodation :
(ii) Diet :
(v) MEDICINES
(vi) Special medicines (list of medicine, cash :
memos and the essentiality cash should
attached)
(vii) Ordinary Nursing
:
(viii) Special nursing i.e. nurses, specially :
engaged for the patient. State whether
are employed on the advice of the medical
Officer-in-charge of the case at the hospital
or at the request of the NHM Employee or
patient. In the former case a certificate
from the medical Officer-in-charge of the
case and countersigned by the medical
superintendent of the hospital should be
attached
(ix) Ambulance charges (state the journey :
to_____________ and from ____________
undertaken)
(x) Any other chrges, e.g charges for electric :
light, fan, heater, air conditioning, etc
State also whether the facilities referred to are a part of the facilities normally provide to all patients
and no choice was left to the patient
I hereby declare that the statements in the 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. In case of any false statement, I understand the amount may be released from me with interest
and I would be liable for any disciplinary action.
Dated: ___________________
Name: Name:
Contact No.: Designation:
E-mail Address:
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To apply for medical reimbursement, the applicant should submit the medical reimbursement
proposal along with the following information:
DOCUMENT CHECKLIST:
Recommendation from District Level Admissibility Board (seal & signature of the Members along
with Admissible amount by name of incumbent concerned is mandatory to furnish along with the
Admissibility Report).
Checklist:
Minutes of the meeting / Check List of the District Level Admissibility Board (seal & signature of the
Members alongwith Admissible amount by name of incumbent concerned is mandatory to furnish
along with the Admissibility Report)
Admissibility Report from the Jt. Director of Health Services (concerned district).
Authorized Medical Attendants recommendation (if applicable).
Referral Medical Board’s Certificate
Essentiality Certificate.
Discharge Summary/Certificate.
Records of Hospital, if applicable
Certificate from the Hospital authority.
Final bill / Bill summary issued by the Hospital authority.
Attested copy of Bank Pass Book.
Birth / Death Certificate (if applicable).
NOK / Legal Heir Certificate (if applicable).
Original bills/vouchers etc.
Leave order for the treatment period (if applicable).
A self declaration / undertaking of no claim from other sources.
Dependent certificate from concerned authority (if applicable).
Physical Verification Certificate of concerned D.D.O.
Recommendation State Admissibility Board (Seal & Signature of the Members along with
Admissible amount by name of incumbent concerned is mandatory to furnish along with the
Admissibility Report).
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