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FORM - MRC (S)

(For serving employees)

CENTRAL GOVERNMENT HEALTH SCHEME

MEDICAL REIMBURSEMENT CLAIM FORM
(To be filled up by the Principal Card holder in BLOCK LETTERS)

1. (a) Name of the Principal CGHS Card Holder

(b) CGHS Ben 10 No.
(c) Employee Code No.
(d) Ward Entitlement - Pvt.lSemi-Pvt.lGeneral
(e) Full Address

(f) Mobile telephone No. and e-mail address, if any

2. (a) Patienfs Name

(b) Patienfs CGHS Ben 10 No.
(c} Relationship with the Principal CGHS card holder

3. Name & address of the hospital I diagnostic center I

imaging center where treatment is taken or tests done:

4. Whether the hospitalldiagnosticlimaging center is

empanelled under CGHS Yes/No

5. Treatment for which reimbursement claimed

(a) OPD Treatment /Test & investigations
(b) Indoor Treatment

6. Whether treatment was taken in emergency Yes/No

7. Whether prior permission was taken for the treatment : YeslNo

8. Whether subscribing to any health/medical insurance YeS/No

scheme, If yes, amount claimed/received

9. Details of Medical Advance taken, if any

10. Totalamountclaimed
(a) OPD Treatment
(b) Indoor Treatment
(c) Testsllnvestigation

11. Name of the Bank: .. SBAIc No.: ..

Branch MICR Code: IFSC Code .

DECLARATIQN
I hereby declare that the statements made in the application are true to the best of my knowledge and belief
and the person for whom medical expensea were incurred ia wholly dependent on me. Iam a CGHS benefiCiary
and the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the
rules.

Date: ..
Place: .. Signature of the Principal CGHS card holder
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