1601979243407-Reimbursement Forms

REIMBURSEMENT CLAIM FORM
1.Name of the Railway/retd. employee (in BLOCK letters) _____________________________________________

2. Designation of the Railway retd. employee (in BLOCK letters) _____________________________________________
3. Office and Station of employment _____________________________________________
4. Pay/Last Pay of the Railway/retd. employee including grade pay___________________________________________
5. Residential address ______ ______________________________________
_____________________________________________
_____________________________________________
_____________________________________________
6. MIC/RELHS no. and issuing Authority _____________________________________________
7. MIC/RELHS registered at Health Unit Hospital _____________________________________________
II.(A) Name and age of the patient _____________________________________________
(B) Patient’s relationship to the Railway/retd. employee _____________________________________________
III. Details of Indoor Treatment at Non Railway Institute
A. Name of Hospital: _____________________________________________
B. Date of Admission: _____________________________________________
C. Date of Discharge: _____________________________________________
D. Diagnosis: _____________________________________________
_____________________________________________
E. Amount of Total Hospital Bill(Attach detailed bill) _____________________________________________
F. Whether Treatment was taken in Emergency _____________________________________________
G. Are you a 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 is to be paid
a) Name of Bank ______________________________b) Account No._____________________________________
c) Branch MICR Code____________________________ d) IFSC Code ______________________________________
VII List of enclosures (Please Tick the documents attached and write additional documents).
A. Photocopy of MIC/RELHS Card
B. Essentiality cum Emergency Certificate by the Non.Rly.Hospital.
C. Discharge Summary
D. Original Bills of Hospital
E. Original Cash vouchers of Drugs/consumables/implants etc. if relevant.
F. Outer pouch of Stent, pacemaker, Implants etc.
G. Any other enclosures______________________________________________________________________________
(In case of many enclosures, write number of additional enclosures here and attach a separate sheet with details)
DECLARATION TO BE SIGNED BY THE RAILWAY EMPLOYEE
I hereby declare that the statements 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 other health scheme in respect to
this treatment episode.
Signature of the Railway employee

Date:
Place:
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 Railway with documents, bills, etc. attested by
insurance company.
________________________Railway
MEDICAL DEPARTMENT
ESSENTIALITY AND EMERGENCY CERTIFICATE
I certify that Shri/Shrimati/Kumar/Kumari _______________________________________ wife

/ son / daughter / dependent relative of Shri / Shrimati___________________________ employed in
Indian Railway as _____________________________________has been under my treatment for
_______________________________________________________________ disease from
_______________to ______________at the _______________________hospital and that the treatment as
described in the attached Discharge Card No._________________ and attached bills thereon 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

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REIMBURSEMENT CLAIM FORM

1.Name of the Railway/retd. employee (in BLOCK letters) _____________________________________________

DECLARATION TO BE SIGNED BY THE RAILWAY EMPLOYEE

Signature of the Railway employee

ESSENTIALITY AND EMERGENCY CERTIFICATE

I certify that Shri/Shrimati/Kumar/Kumari _______________________________________ wife

Signature of Hospital In-charge or

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