Tel no. 26588980, 26588707, 26589336 een fof / SCIENTIFIC Fax : 011-26588662, 26589791 + jomrbads@sansed icin ade srghtsrs arene aR INDIAN COUNCIL OF MEDICAL RESEARCH &. unferreantt aan, seat any, dee afer 4071, ag Reet - 110 020 ‘V.RAMALINGASWAMI BHAWAN. ANSARI NAGAR. POST BOX 4911.NEW DELFUI- 110029 'No.1/3/2002-Admn.I(CGHS) Dated : 30.10.2014 To ‘The Directors/Directors-in-Charge of all perment Institutes/Centres of ICMR. Sub: Revision of Medical Reimbursement Claim (MRC) Form for CGHS beneficiaries ~ reg. Sir/Madam, Please find enclosed herewith a copy of O.M. No.8.11011/9/2012-CGHS (P), dated the 5 June, 2014 from Ministry of Health & Family Welfare, CGHS (Policy), New Delhi on the subject mentioned above for information and necessary action Yours faithfully, fghew” (Bharat Bhushan) Admn. Officer For Director-Generalg No. S. 11011/9/2012.cGHs (P) Government of India Ministry of Health & Family Welfare CGHS (Policy) Nirman Bhawan, New Delhi Dated the 5" June, 2014 OFFICE MEMORANDUM Sub:- Revision of Medical Reimbursemont Claim (MRC) Form for CGHS beneficiaries - reg, {jhe undersigned is directed to state that it has been the constant endeavour ofthe Ministry of Health & Family Welfare to improve the tachnex under CGHS and Simplify / liberalize the procedures to make the Scheme user friendly. 2.» in furtherance of the above objective, the Medical Reimbursement Claim Form has been reviewed and further simplited. Separate fees have been Aeveloped for serving beneficiaries and pensioner beneficianes von requirement of ininimum information required for processing ofthe claims. The Genie beneficiaries 3. The following forms have been prescribed: Form MRC(S) - For Serving CGHS beneficiaries, Form MRC(P) - For Pensioner CGHS beneficiaries. ‘Specimen Forms are enclosed Encl: As Above IVP. Singh] Director Telefax: 2306 1834 unl Abe a All Ministries / Departments, Government of India Director, CGHS, Nirman Bhawan, New Delhi Addl. DDG(HQ), CGHS, MoHFW, Nirman Bhawan, New Delhi AD(Hq), CGHS, Bikaner House, New Delhi All Additional Directors /Joint Directors of CGHS cities outside Delhi Additional Director (SZ (CZ)MEZ)(NZ), CGHS, New Delhi JD(HQ\JD (Gr. JD(R&H)(MSD), MCTC, CGHS Delhi CGHS MINN, Dte. General ‘of CGHS, Nirman Bhavan, New Delhi Estt.l/ Estt.t1/ Estt.lI/ Estt.v Sections, MoHFW, Nirman Bhawan, New Dethi ion, MoHFW, Nirman Bhawan, New Delhi Admn.t/Admn.it / MG Sections of Dte.GHS, Nirman Bhawan, New Dethi Contd.....2/- SONOMA R EVA G #3 = 5 8 a g1.0) ® © @ ee o 2@) ) © 10, " EDICAL REIMBURSEMENT. FORM —~ MRc (s) (For serving employees) CENTRAL GOVERNMENT HEALTH SCHEME SERSAL GOVERNMENT HEALTH SCHEME MEDICAL RE CLAIM FORM (70 be filed up by the Principal Card holder in BLOCK LETTERS) Name of the Principal CGHS Card Holder CGHS Bon ID No. Employee Code No, Ward Entitlement ~ Pvt /Semi-PvtsGeneral Full Address Mobile telephone No, and e-mail address, i any Patient's Name Patient's CGHS Ben ID No. Relationship with the Principal CGHS card holder Name & address of the hospital / diagnostic center / Imaging center where treatment is taken or tests done: ‘Whether the hospitalidlagnostioimaging center is ‘empanelied under CGHS. Treatment for which reimbursement claimed (@) OPD Treatment /Test & investigations () Indoor Treatment Whether treatment was taken in emargonoy Whether prior permission was taken for the treatment Whether subscribing to any heelth/medical insurance ‘Scheme, If yes, amount claimedireceived Details of Medical Advance taken, if any Total amount claimed (@) OPD Treatment (©) Indoor Treatment (©) Tests/investigation Name of the Bank Branch MICR Code: 88 Ac No. WSC Code... Yes/No YesiNo Yes/No YesiNoPhoto copy of the CGHS card of the employee along with the patient's CGHS Card, Copy of permission letter, i any. Emergency certlicate (original) in case of emergency. Copy of the discharge summary. Ambulance Certificate (original, if any. Original bils ‘cash memo / vouchers etc. forthe reimbursement amount claimed. IMPORTANT Kindly ensure to provide the following information / documents, wherever applicable: 2) » ° 4 °) Obtain Break up of Investigations from the hospital/diagnostic center/imaging center (details and rates of individual tests and the exact number of tests, X-ray flms, etc.) as the reimbursable amount is calculated as per approved CGHS rates per test. In case of loss of original papers, Affidavits as per Annexure | to be submitted. All photocoples of the bills to be attested by the treating doctor/specialis. {In case of death of the card holder, Affidavit as per Annexure II to be filed and attached to claim reimbursement, In case of implants, Invoice No. along with sticker with seriel number of the implant to be attached, In case of Coronary Stents, cuter pouch of stents is to be enclosed, In caso of replacement of pacemaker / ICD ete, copy of the warranty certificate of earlier Pacemaker/ICO may be enclosed. Note: Misuse of CGHS facilities is a criminal offence. Penal action including cancellation of CGHS card may be taken ‘in case of wilful suppression of facts or submission of false statements. Sultable disciplinary action shall be faken in case of sorving employees,Annexure -I Draft for Affidavit for Duplicate Claim Papers/bills on stamp Paper . and resident of “have. lost / misplaced the original paper or the same are not traceable, | hereby give an undertaking thet | have not received any payment against the original bills/claim papers from any source and that if the original papers are traced, | shall not stake claim against original bills in future and that in the event, | receive any cheque against the original bills in future, | shall return the same to competent authority. son / wife / daughter of... Deponent Verified by Notary PublicFORM - MRC (P) (For ponsioner beneficiaries) CENTRAL GOVERNMENT HEALTH SCHEME MEDICAL REIMBURSEMENT CLAIM FORM (To be filled by the Principal Card holderiClaimant in BLOCK LETTERS) 4.(@) Name ofthe Principal CGHS Card Holder (©) CGHS Ben ID No. (6) CGHS Wetness Center to which the card is attaches (@) Validly of CGHS Card (e) Ward Entitlement — Pvt/Semi-Pvt/General Full Address (9) Mobile telephone No. and e-mail address, if any 2. (a) Pationt’s Name (b) Patient's CGHS Ben ID No. (@) Relationship with the Principal CGHS card holder 3. Category of pensioner beneficiary please specify (Central Govt. Pensloner/Pensioner of Autonomous/Statutory bedy/Ex- MP/ Ex-Governor/ Former Judge of Supreme Court/ Former Judge of High Court/Freedom Fighter/Legal Heir/Others) 4, Name & address of the hospital / diagnostic center / imaging center where treatment is taken or tests done: 5, Whether the hospital/dlagnostic/imaging center is ‘empanelied under CGHS YesiNo 6 Treatment for which reimbursement claimed (@) OPO/Test & investigations (©) Indoor Treatment 7. Whether credit facility was avelled. 1 not, reasons thereof (clarification may be attached) 8. Whether treatment was taken in emergency YesiNo 9. Whether prior permission was taken for the treatment YesiNo 10. Whether subscribing to any healthimedical insurance YesiNo ‘scheme, If yes, amount claimedireceived 11, Total amount claimed (@) OPO Treatment , (b) Indoor Treatment (0) Testsiinvestigation 12. Name ofthe Bank... ‘8B Alc No, Branch MICR Code... . . IFSC Code DECLARATION | hereby declare that the statements made in the application are true to the best of my knowledge and belief end the person for whom medical expenses were incurred is wholly dependent on me. am a CGHS beneficiary and the CGHS card was valid at the time of treatment, { agree for the reimbursement as is admissible under the rules.Documents to be attached Photo copy of the CGHS card of the principal card holder along with the patient's CGHS Card, Copy of permission letter, if any. Emergency certificate (original), in case of emergency, Copy of the discharge summary. ‘Ambulance Certificate (original), if any. Original bills ‘cash memo I vouchers ete. forthe reimbursement amount claimed. IMPORTANT. Kindly ensure to provide the following information / documents, wherever applicable’ 2) Obtain Break up of investigations from the hospitaldiagnostic centerimaging center (details and rates of individual tests and the exact number of tests, X-ay flms, etc.) as the reimbursable amount is calculated as er approved rates per test. b) In.case of loss of original papers, Affidavits as per Annexure { to be submitted. All photocopies of the bills to be attested by the treating doctor/specialist. ©) In case of desth of the card holder, Affidavit as per Annexure II to be filled and attached to claim reimbursement, ©) Incase of implants, Involce No. along with sticker with serial number of the implant fo be attached. 4) Incase of Coronary Stents, outer pouch of stents is to be enclosed. ©) In case of replacement of pacemaker / ICD etc., copy of the warranty certificate of earlier pacemaker /ICD may be enclosed. Note: Misuse of CGHS facies is a criminal offence. Penal action including cancellation of CGHS card may be taken ‘In case of wilful suppression of facts or submission of false claims / statements.Annexure -! Draft for Affidavit for Duplicate Claim Papers/bills on stamp Paper hae son / wife / daughter of. coseonieineens and resident of have lost / misplaced the original paper or the same are not traceable. | hereby give an undertaking that | have not received any payment against the original bills/claim papers from any source and that if the original papers are traced, | shall not stake claim against original bills in future and that in the event, | receive any cheque against the original bills in future, | shall retum the same to competent authority. Deponent Verified by Notary PublicAnnexure = Il Draft for Affidavit on Stamp Paper for claiming medical reimbursement IN CASE OF DEATH of a CGHS Card Holder husband / wife / son / daughter of Late. and resident “of .. hereby submit the medical reimbursement claim papers pertaining to treatment of my husband / wife / father / mother Late Shrif Smt.........:0 who has expired OM .sccsessee (copy of Death Certificate is enclosed). Late Shri/Smt........ccec en ..-has left behind the following other legal heirs, none of whom have any objection if the entire reimbursable amount is paid to me. No Objection Certificate signed by other legal heirs on Stamp paper is enclosed. Deponent Attested by Notary Public ssw. So Dio Late Shri. .. S/o Dio Late Shi . S/o Dio Late Shri. © being the legal heirs of Late Shri/Smt.. . . enti amount reimbursable pertaining to the treatment of late Shri / Smt is paid to Shri / Smt “have no objection if the () (Gignature) (ii) ( Signature ) (ii) (Signature) Name: Name Name Address: Address: Address (iV) eccesceccesseresteetesneee WW). ccssteneenees (vi). Verified by Notary Public