[APPLICATION FORM FOR CASHLESS SMART CARD FOR RELHS BENEFICIARIES (Please fill in Capital Letters) (Recent Coloured Passport Size Photo to be affixed) To be attested by the CHP Application Registration Form No. Date of RELHS Card registred: Health Unit where cared's registered: PPO No: Last Pay drawn & deposited for RELHS Card: Present Pension: PARTICULARS OF PENSIONER: 1. "Name of Retired employee who is registered in RELHS Oaroens Age: 2. Identification Marks: 3‘ Date of birth of Applicant: 4 Permanent Address: a Present Address: Telephone Number : Mobile No: RELHS Card No. & issued by : 9. CMC No.of Central Hospital: 40 Email address: 11. Blood Group: e192 Signature & Thumb Impression of the Applicant.es The Personal data of the dependants : (Recent coloured Ae rad Passport Size the CHIJP 4 Name: 2 Age i 3 MO: 4 Blood Group: ‘Signature/Thumb Impression (b) Child (Dependant) (Recent coloured 1 Name: Passport Size Age: _ [Photo to be affixed) To be attested by 2 Date of birth : the CH/JP 3 MOL 4. Relationship(Son/Daughter): 5 Employed (Y/N): 6 “Married/Unmarried: 7 Blood Group: : Signature/Thumb Impression (cc) _ Widowed Dependant Mother: 1 Name: ‘(Recent coloured ge: Passport Size Photo to be affixed) Tobe attested by 2 Date of Birth: the CHNP 3. Identification Marks : 4. Blood Group: Signature/Thumb Impression (d) Any other Dependants :ag ‘Sample of Affidavit AFFIDAVIT ON Rs.10/- NON-JUDICIAL STAMP PAPER AND TO BE ATTESTED BY MAGISTRATE/NOTARY PUBLIC DECLARATION 1. Shri/Smt (place}.... Retired employee of Dept .. from solemnly affitm and declare as fallows:- |. Tam drawing Pension vide PPO No. hat I have the legal dependant(s) whose photographs is/are affixed below on this Affidavit 2 Date of Birth. Names. Relationship. sage. Signed Photo of Self’ & Dependants giving name, relationship and identification mark (Photographs to be pasted and signed across by each dependant, In case of challenged child/minor, to be signed by Applicant). . - That my son(s) is/are NOT employed and that | am aware that my son(s) are not eligible for the RELHS after he/they get employed at any time, | shall inform the Railways immediately of his/their employment s That my daughter(s) is/are NOT married. That } am aware of the fact that my daughter(s) is/are NOT eligible for their RELHS afier she/they. get married. 1 shall immediately inform RELHS authorities’ of her'their marriage. E - That in case of any change in the status of my dependants (due to death, marriage, employment), 1 will inform RELHS at the earliest and will stop use of the RELHS facilities. 1 will refuund in full, the cost of any treatment that my dependants may have received after he/she became ineligible. 1 shall be liable for civil/criminal action should I fail to do so, . That I am not a member of any other medical scheme funded by Central Govt. PSU, or any other Govt. undertaking. 2 1 understand that in case I have submitted any incorrect information, or if my RELHS card is misused or used by any unauthorised person, my ’ membership will be cancelled without any notice or further hearing. In addition, I will forfeit my contribution and will pay:the entire cost of expenditure incurred on such unauthorised person(s). I will also be liable fora legal action by the RELHS. 1 wil] also immediately report the loss-of my RELUS card to the Health Unit and lodge an FIR with the local civil police, + hatin case of misuse of Smart Cards) or tampering with bills or attempt to Geffaud once I become a member, wil forfeit my membership automatically, Signature of Deponent VER! 0) {The deponent above named, do hereby solemnly declare and verity that the Perens ph the above affidavit are true to the best of my knowledge and belie and no material has been concealed or suppressed tho from, | Verified at (Place), “on this (Date). day of (month)... -. (Year) Signature of the Deponent, ATTESTATION Certified that the above statement is declared before me at (Place)... 2.on thi (Month).:...(Yea who is identified by........ identifier), and witnessed name of first witness). Father's name of second witness), WITNESS Signature of Witness no. 1 (Name in Block Capitals) (Pull Postal Address) Signature of Witness No. 2 (Name in Block Capitals) (Full Postal Address) ATTESTED BY MAGISTRATE/NOTARY PUBLICaS 55 4 ; C® CASHLESS SERVICES FOR RELHS -ARD HOLDERS TO. : CASHLESS SERVICES FoR TAKE TREATMENT IN RECOGNIZED PRIVATE * HOSPITALS IN EMERGENCY Terms & Conditions of the Scheme i Fhe scheme isto be implemented in all the Metros, State Capitals and Zonal Headquarters it, onal Railways shall enter iato an “MOU’ with already empaneled hospitals under thei jurisdiction fF the scheme. Further, if tere are not enough recognized multi-specialty hospitals, zonal Railways shall recognize CGHS emparelled hospitals on CGHS approved rates and/or other hospitals as per extant policy and enter into an ‘MOL? for the Smart Card Shceme. Smart Card should provide necessary demographic data and other relevant information on a standardized fotmat. pee. Zonal Railways shall award the job of issuing the Smart Catd to a uiuble services provider on most competitive rates, through open bidding. Tt shall be the responsibility of the hospital to inform the authorized medical attendant regarding emergency within 24 hours. In case an ‘dmission is found to be of non-emergency nature, the treating hospital Stall refer the patient to authorized medical attendant in next 24 hows, ‘The scheme shall be implemented with the existing man power of Zonal Railways. 2 1 Issuance of Smart Card is made mandatory to RELHS benefiiares residing in the regions mentioned in () above and cost of the card as ferided upon may also be included in the contribution towards joining RELHS atthe time of retirement. The following conditions, shall qualify as emergencies, + Acute cardiac conditions/syndromes. * Vascular catastrophes, Cetbo-vascular accidents. * Acute respiratory emergencies, * Acute abdomen including acute obstetrical. gynecological emergencies, + Life threatening injuries. * Acute poisioning and snake bite. ‘+ Acute endocrine emergencies. + Heat stroke and cold injuries ofa life threatening nature. * Acute renal failure. + Severe infections leading to life threatening situations * Any other condition in which delay could result in loss of life or limb. aBr EMPENELMENT OF HOSPITALS AND THE SPECIALITIES FOR WHICH THEY ARE RECOGNISED Name of Hospital Recognised for Date of Expiry | Heart and General Hospital, | Cardiology 14.06.2013 Jaipur g = SK Soni Hospital, Jaipur | Cardio, OT Surgery, Gastro. 17702013 ’ Neonato., Nephro:, Urology, Dialysis, Neuro., Neuro-Surgery, ~ | & Critical Care. Sea Rec Hospital, Jaipur | Cancer BMCH & RC, Jaipur Cancer s Fortis Escort Hospital, Cardio, Neuro-Surgery, Renal Jaipur Sc., Orth, Joint Repiace., Critical Care