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Government of West Bengal

Finance Department
Audit Branch Medical Cell No. 6953-F (MED) Memorandum In the process of implementation of the West Bengal Health Scheme, 2008 the Government from some time past was considering for amendment of Forms regarding enrolment under the Health Scheme and settlement of claims. Accordingly, the Governor is pleased to publish the following amended Forms under the West Bengal Health Scheme, 2008 and guidelines for settlement of claims. 2. Under Clause-7 (1) of the West Bengal Health Scheme, 2008, costs of OPD treatment of ten listed diseases are reimbursable. Reimbursement of the cost of medical treatment of such diseases may be allowed when the attending physician of recognized hospital clearly certifies that the beneficiary was/ has been suffering from any of the listed diseases of Clause-7(1) of the Health Scheme. Essentiality Certificate for treatment under Clause-7 (1) of the Health Scheme should be furnished in Form-‘D1’/ Form-‘IV1’. Cases relating to Clause-6, Clause-7 (2) or Clause-9 of the Health Scheme may be settled following provisions of those Clauses. Essentiality Certificates for those cases should be furnished in Form-‘D2’/ Form-‘IV2’. 3. Revised terms and conditions for rendering services under the Health Scheme and revised rate list have been published under the notification no. 796-F (MED), dated 31-012011. Guidelines for settlement of claims along with list of inadmissible items have also been published under the memo nos. 797-F (MED), dated 31-01-2011 and 6586-F (MED), dated 29-06-2011 respectively. Accordingly, all claims should be settled strictly following the provisions of the Health Scheme, guidelines and rate list. 4. For enrolment and settlement of claims under the Health Scheme, henceforth, revised Forms shall be used (attached herewith). 5. Health Scheme with amendments, revised rate list, list of empanelled and recognized Health Care Organisations, Forms, Guidelines and related Government Orders, Memorandum of Agreement with the Health Care Organisations may be available in the official website of the Finance Department www.wbfin.nic.in – West Bengal Health Scheme, 2008. Sd/- S.K. Chattopadhyay Officer on Special Duty and Ex-officio Special Secretary to the Government of West Bengal Dt. 11-07-2011

West Bengal Health Scheme, 2008

FORM A
Application for enrolment under the West Bengal Health Scheme, 2008. (See sub-clause (1) of clause (4) TO: The ___________________________ (Cadre Controlling Authority/ Head of Office)

Sir, I Shri/ Smt ___________________ (Designation) ____________________________ attached to _____________________ (office) under __________________________ (Department) do hereby opt for coming under the West Bengal Health Scheme, 2008 with effect from 1st day of ____________, _________. (Month) (Year) The particulars of the members of my family as defined in para 3(e) of the Scheme as amended under notification no. 6722-F dt. 09.07.09 are as follows: Name of Government Employee Designation Residential Address : : :

Date of birth Date of entry into Government Service Date of superannuation Present pay (Band pay + Grade pay) G.P.F. A/C No. Details of Family Sl. NO: Name 1. 2. 3. 4. 5. ____________________ ____________________ ____________________ ____________________ ____________________

: : : : :

Date of Birth/ Relationship Monthly income, Age if any ___________ __________ ______________ ___________ __________ ___________ __________ ___________ __________ ___________ __________ ______________ ______________ ______________ ______________

I do hereby declare that upon enrolment under the above scheme I shall forgo the regular monthly medical allowance drawn by me as a part of salary. I further declare that I shall abide by the provisions of the West Bengal Health Scheme, 2008, as may be in force from time to time.

_____________________ Signature of the Applicant

West Bengal Health Scheme, 2008

FORM B
Certificate for enrolment under the West Bengal Health Scheme, 2008 (See sub-clause (3) of clause 4)

Certified that Shri/Smt. ___________________________ (designation) _________ _____________ _______________________ attached to _______________________ ____Department has been enrolled under the West Bengal Health Scheme, 2008, with effect from 1st day of _____________, _________. (Month) (Year)

The particulars of the Govt. employee and dependent members of family as defined in para 3(e) of the Scheme and amended under notification no. 6722-F dt. 09.07.09 are as follows: Name of Government employee Designation Residential address : : :

Date of birth Date of entry into Government service Date of superannuation Present pay (Band Pay + Grade Pay) G.P.F. Account No. Details of Family Sl. No. Name 1. 2. 3. 4. 5.

: : : : :

Date of birth/Age

Relationship Monthly income, if any

Signature of the Cadre Controlling Authority/ Head of the Office

Finance (Audit) Department. Kolkata. Treasury Buildings. 4.Medical Cell. Kolkata. 3. No. He is requested to discontinue the drawal of regular monthly medical allowance in respect of Shri/ Smt. Writers’ Buildings. ________. _____________ Copy forwarded for information and necessary action to: 1.1. Signature of the Cadre Controlling Authority/ Head of the Office .Accountant General (A&E). 2008 Memo. (Year).Shri/ Smt _______________________________________________ (designation) 2. ______________________________with effect from 1st day of __________ (Month).The _____________________________________ (Drawing and Disbursing Officer).West Bengal Health Scheme. __________ Dt.

Date of superannuation 6. 2008 FORM C Application Form for settlement of claim for reimbursement under the West Bengal Health Scheme. Enrolled under the Health Scheme w. Pay (Band Pay + Grade Pay) 7. Name of the beneficiary & relationship with the Government employee 10. of the Govt. Medical treatment done 9.West Bengal Health Scheme.e. 2008 (See sub-clause (1) of clause 12) (To be filled in by the applicant) 1. employee : 2. Accommodation Category [put (√) mark)] 8.f. Identification No. (a) OPD treatment : : : Private/ Semi-Private/ General Ward : Self or beneficiary : : (b) Indoor treatment/ Day Care : 11. Disease : : : . Name of the Hospital with address and code no. Period of OPD treatment 12. Full name of the Govt. Period of indoor treatment 13. employee with designation (in Block letters) 3. Full Address: (i) Office : : (ii)Residence : 4. : 5.

dt. Details of Medical advance. Signature of the Govt. and the enrolment under the Scheme was valid at the time of treatment. 31-01-11. I am a beneficiary of the West Bengal Health Scheme. if any (a) Amount (b) Order no. I agree for the reimbursement as is admissible under the rules. 16. Total amount claimed(a) OPD treatment (b) Indoor treatment Total : : : 15. and date (c) Sanctioning Authority : : : DECLARATION 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 expenses were incurred is wholly dependent on me. Employee Date: . etc. digital hearing aid. 797-F (MED). as per Memo No. 2008 14.West Bengal Health Scheme. 2008. Details of permission (a) For treatment in speciality hospital : outside the State (b) For human organ transplantation/ : ICD/ CRT/ Dual Chamber Pacemaker/ more than two stents/ more than one drug eluting stents.

Details of expenditure: (I) Name of the diagnosed disease * ( vide list enclosed) : (II) Name & Code No. of original vouchers & money receipts (V) Amount claimed for OPD treatment : : : Amount admissible (for official use) Sl.) Medicines (give details of purchase in separate annexure. of consultations) Pathological investigations (give Break-up in a separate annexure with code no. of the empanelled/ Govt.) Radiological investigations (attach separate list. 2008 FORM “D1” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for OPD Treatment [See sub-clause 12 (3) & clause 7(1)] 1. Name of Office of the Govt. with code no. No.West Bengal Health Scheme. employee with identification No. Name of the Govt. Name of the patient. 2. : 4. (specify) Amount Claimed (b) (c) (d) (e) . relationship with Govt. recognized Hospital : (III) Period of OPD treatment (IV) Total No. if required. if required) Special devices like hearing aid/artificial appliances etc. Employee & identification No. employee with address : : 3. (a) Description of items Consultation fees (indicate total no.

West Bengal Health Scheme. 2008 and the expenditures shown above are correct and the treatment services prescribed and provided were essential and minimum that required for the recovery of the patient. 797-F (MED). Sri/Smt. (xi) None of the above list (Specify name of the ailment) [vide Para-10 of Memo No. (viii) Renal failure. (x) Injuries caused by accidents. Counter signed by (Signature of the Treating Specialist with official seal) Administrative officer/Medical Superintendent of the empanelled/ recognized Hospital with official seal * OPD Disease List as per clause –7 of the WBHS. 2008 (i) Malignant diseases. No. 2008 (f) Miscellaneous (specify) Total (Rupees: only) (Signature of Claimant) Name in Block Letters Address: 1.__________________ of the WBHS OPD list below*. (v) Heart diseases. (ix) Thallasaemia/Bleeding disorders/Platelet disorders. (iii) Hepatitis B/C and other liver diseases. (vii) Malignant malaria. (ii) Tuberculosis.__________________________ was/ has been suffering from___________________as listed in Sl. Certified that the relevant bills/vouchers have been verified by me in pursuance of the latest approved rates of the WBHS. 2. (iv) Insulin-dependent diabetes. dated 31-01-2011] . (vi) Neurological disorders/Cerebrovascular disorders. Certified that the patient.

employee with address : : 3. of original vouchers & money receipts (V) Details of Amount claimed (A) for Package treatment from ______ to ______ : : : : : Sl No. employee with identification No. Name of the patient. Employee & identification No. Name of Office of the Govt. : 4. Name of the Govt. clause 7(2) & clause 9] 1.West Bengal Health Scheme. 2008 FORM “D2” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for Indoor/Day Care Treatment and related OPD treatment [See Clause 12(3). (1) (i) (ii) (iii) (iv) (v) Procedure Name (2) Procedure Code No. clause 6. 2. if necessary) Total=Rupees . of the empanelled/ Government recognized Hospital (III)Period of Indoor/Day Care treatment (IV)Total No. Details of expenditure: (I) Name of the diagnosed disease (II) Name & Code No. (3) Amount Claimed (Rupees) (4) Amount admissible (Rupees) (for official use) (5) Miscellaneous (Specify & give details in separate sheet. relationship with Govt.

West Bengal Health Scheme. _____ (1) (i) (ii) (a) (b) Description of items (2) Consultation fees (indicate total no. (1) (i) Description of items (2) Room Rent : (a) Ward (b) ICU/ ITU/ CCU/ NICU/ PICU (c) HDU/Step Down Unit/Burn Unit Item Code (3) (ii) Charges for : (give details with code nos. 2008 (B) for Non-Package treatment from ______ to _______ Amount Claimed (Rupees) (4) Amount admissible (Rupees) (for official use) (5) Sl No. in separate annexure) Pathological investigations Radiological investigations (c) Medicines . in separate annexure) (a) Indoor visit of specialist/ super specialist (b) Radiological Investigations (c) Pathological Investigations (d) Medicines (e) Artificial devices (f) Miscellaneous (specify) Total : (VI) Related OPD treatment in terms of Clause-9 or Clause-7(2) Amount Claimed (Rupees) (3) Amount admissible (Rupees) (for official use) (4) =Rupees ___________ ___________ ____________ ____________ Sl No. of consultations) Charges for : (give details with code nos.

West Bengal Health Scheme. 2008 and the expenditures shown above are correct and the treatment services provided were essential and minimum that required for the recovery of the patient. (specify) Miscellaneous (specify) = Rupees =Rupees only) (3) (4) ___________ ____________ ______________ ______________ (Signature of Claimant) Name in Block Letters Address: 1. Conservative treatment provided from __________________ to __________________. (Signature of the Treating Specialist with official seal) Countersigned by Medical Superintendent/ Administrative officer of the empanelled/ recognized Hospital with seal . 2. Specific procedure/Operation performed was ___________________________ on _______________. Certified that the services of Special Nurse/Ayah were required from ________________ to ______________ that were absolutely essential for the recovery of the patient. Certified that the relevant bills/vouchers have been verified by me as per latest approved rates of the WBHS. 2008 (1) (d) (e) Total: Grand Total (package + non-package+ OPD amount) (Rupees: (in words) (2) Special devices like hearing aid/artificial appliances etc. 3. 4.

if required) Amount Admissible (60% of approved Package rate) (Rupees) (for official use) (5) Sl. Name of Office of the Govt. : 4. No. 2 Name of the Govt. 797-F (MED). of original vouchers : : Details of Amount claimed: (give details in separate annexure. _______ (1) (i) (ii) (iii) Description of items (* vide list enclosed) (2) Treatment Period (3) Amount claimed (Rupees) (4) .2011] 1. relationship with Govt. employee with identification No. Employee & identification No. employee with address : : 3 Name of the patient. Details of expenditure: (I) Name of disease (* vide list enclosed) Name & Address of the Hospital : (II) : (III) Period of treatment (IV) Total No.West Bengal Health Scheme.01. dt. 2008 FORM “D3” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for treatment services taken from WB Health Scheme non-recognised Private Hospital/ Nursing Home [See Para-23 of the FD memo no. 31.

3. Certified that the relevant bills/vouchers have been verified by me and the expenditure shown is correct and the treatment services provided were essential and minimum that was required for the recovery/stabilization of the patient. . (b) Acute Appendicitis operation on emergency basis. 31-01-2011 (a) Accidental injury.West Bengal Health Scheme. Countersigned by Medical Superintendent/ Administrative officer of the Private Hospital/ Nursing Home with seal (Signature of the Treating Specialist with official seal) *List as per Para 23 of Memo No. (d) Haemodialysis. dt. (e) Removal of foreign body on emergency basis. The Specific procedure/Operation performed was _____________________________ on _______________. Certified that the treatment was done in an organization that has a License under the West Bengal Clinical Establishment Act and Rules and the licence no is __________________________ and is valid up to ____________. (c) Delivery on emergency basis. Certified that the patient had been admitted under my care at _________________Hospital/Nursing Home as an emergency case. 2. 797-F (MED). 2008 (iv) Total= Rupees ____________ _________________ (Rupees: (in words) only) (Signature of Claimant) Name in Block Letters Address: 1.

Whether claim is for employee himself or his beneficiary. 2008 FORM E Checklist for Reimbursement of Medical Claims/ Sanction of Advance (See sub-clause (3) of clause 12) 1. Whether treatment was done in non-empanelled hospital : Yes/No If yes – a) Name of the hospital/nursing home with Clinical Establishment licence No. (a) Name of office with address (b) Directorate (c) Department 4. Notification No. 796-F (MED).West Bengal Health Scheme. mention – : : : : : : a) Name of the beneficiary and relationship with employee : b) Beneficiary’s Identification No. Period of treatment: a) OPD b) Indoor/ Day Care treatment 10. Employee’s Identification No. & date c) Sanctioning Authority 11. Details of advance sanctioned a) Amount b) Order No. 2008) (ii)Copy of permission letter furnished : (For human organ implantation/ Dual-chamber pacemaker/ AICD/ CRT/ more than one drug eluting stents Implantation. . & date of enrolment 2. Full name & designation (block letters) 3. and address : 9. etc. Disease : Private/Semi-Private/General ward : 7. Name of the hospital where treatment was done/to be done /is going on : 8.) (Vide Para-8 & 9 of Finance Deptt. : Yes/No. : c) Validity of the Card up to : 5. Yes/No. if for his beneficiary. dated 31-01-2011) b) Treatment done outside the State – Copy of permission letter furnished Yes/No. a)Treatment done within the State- : from _________ to_________ : from _________ to_________ : : : (i) Copy of intimation letter furnished : (Vide Clause-11 of the West Bengal Health Scheme. Entitlement of accommodation (Put tick mark) 6.

.. Yes/No Yes/No... Yes/No.. etc.... (A) Whether the claim for reimbursement has been preferred within (i) three months from the date of discharge of indoor treatment (ii) three months from the date of consultation of OPD treatment (iii) three months from the date of purchase of medicines.. Signature of the Applicant ... 2008 12....West Bengal Health Scheme. The following documents are submitted (please tick [√] the relevant column) (a) Photocopy of the Health Scheme Identity Card of I) Govt... Yes/No.... (i) In case of death of Govt.. Dated.... Yes/No... employee following documents are submitted(I) Affidavit on stamp paper by claimant : Yes/No. Yes/No Yes/No Yes/No (h) Original papers have been lost the following documents are submitted(I) Photocopies of claim papers (II) Affidavit on stamp paper (III)Photo copy of Police Diary : : : Yes/No... (II) No objection from other legal heirs on stamp papers : Yes/No.. employee II) Beneficiary (b) Essentiality Certificate (as specified) (c) Copy of discharge summary (d) Copy of OPD prescription (e) Total Number of original bills & cash memos (f) Detailed list/Statement of medicines furnished (g) Detailed list of investigations furnished : : : : : : : : : : : : : Yes/No. whether delay in preferring claim has been condoned by the West Bengal Health Scheme Authority under the Finance Department 13. (III) Copy of death certificate : Yes/No.. (for continuous OPD treatment) (B) If not..

5.West Bengal Health Scheme. Name of the Government employee 2.* Signature of Cadre controlling authority /Head of the office. 4. 3. Date of birth 7. No. This permit is valid for 6 (six) months from the date of enrolment. Date of Superannuation 8. No. . 2008 in the entitled class mentioned in Sl. Employee Identification No.* The temporary family permit is valid till the New entrant Government employee gets G.P. Designation 4. Age Relationship : Monthly Income. 5. (GPF No. Residential address : : : : : : : : 9. 2008 FORM-F Temporary Family Permit [See sub-clause (9) of clause 10] 1.F. Photograph (Stamp size) Shri/Smt. No. recognised under the West Bengal Health Scheme. * Strike out whichever is not applicable. 2. Details of Family Sl. Present Pay (Band pay+ Grade Pay) 5. 2008 with effect from __________________ He/She and his/her family members are entitled to the medical attendance and treatment in a Government Hospital/empanelled Private Hospital or Institution etc.) 3. ______________________________________attached to _____________ _______________________________________________________________ (office) under _________________________________________________________ Department has been enrolled under the West Bengal Health Scheme. Name 1. Entitlement of accommodation 6. If any.

(* Strike out whichever is not applicable) My particulars are given below 1. Name of Treasury with address : (In case of Pensioners residing in the districts) 9. 1st day of ……………. 5.09. Date of Retirement/Death : 4. 3. Name : Date of birth/Age Relationship Monthly income. 2008 w. Ex-Govt. Details of Family Sl. 3475 F dt. and address : (In case of Pensioners residing in Kolkata) 10. / I ____________________________ family pensioner along with dependent family members of my late husband/ wife. No. Department/ Office where rendered services : 5.(month)……………. No. 4. 2. 12 may be enrolled under the West Bengal Health Scheme. Signature of the Applicant .] To The……………………………… (Pension Sanctioning Authority/ Competent Authority) Dear Sir. 2008 FORM I Application for enrolment under the West Bengal Health Scheme. 1.05. No. Basic Pension(before commutation) 7.f. 2008 with effect from 1st day of ……………. employee at Sl. if any I do hereby declare that upon enrolment under the above scheme I shall forgo the regular medical relief drawn by me as part of pensionary benefits. I further declare that I shall abide by the provisions of the West Bengal Health Scheme.(month)…………(year). along with my dependent family members whose particulars are given below at Sl. 11.(year). Pension Payment Order No. Name of the Ex-Govt. under the Health Scheme : during service period before retirement/ death 12. 12 may please be enrolled under the West Bengal Health Scheme. 2008 as may be in force from time to time. Identification no. Whether a beneficiary of the Health Scheme during service period : 11.e. Employee 2. Last Pay (Band Pay+ Grade Pay) drawn before retirement/ death 6. 2008 (Government pensioner/ family pensioner) [See sub-para (iv) of para-4 of memo no. : : : 8. Residential Address : : 3. Name of Bank with account no.West Bengal Health Scheme. I.

09 are as follows:1. family pensioner has been enrolled under the West Bengal Health Scheme. 3475 F dt.05.West Bengal Health Scheme. 8. 11.] Certified that Shri/ Smt ________________________________________ . Basic Pension (before commutation) : 7. employee and members of family as defined in para 3(v) of memo no. with effect from 1st day of ____________ (Month). Department/ Office where rendered : services 5. Last Pay (Band Pay+ Grade Pay) drawn before retirement/ death 6. dt. 7071-F. 2008 FORM II Certificate of enrolment (Government pensioner/ family pensioner) [See sub-para (v) of para-4 of memo no. Date of Retirement/ Death 4.09. 2008. 20. Pension Payment Order No. ________ (Year) (* Strike out whichever is not applicable) The particulars of the Ex-Govt.09 read with memo no. Employee 2. with effect from 1st day of ____________ (Month). 3475-F dt. ________ (Year)/ Certified that Shri/ Smt _______________________. Residential Address : : 3.07. Ex __________________________________________________ who was attached to _________________________________________________________ (office) under _____________________________ Department has been enrolled under the West Bengal Health Scheme. 2008. Name of the Ex-Govt.05.11. Name of Treasury and Bank with address from where pension is drawn (In case of Pensioners residing in the districts) : : : : .

No. under the Health Scheme during service period before retirement/ death 11.West Bengal Health Scheme. Identification no. 5. Name : Date of birth/Age Relationship Monthly income. The Accountant General (A & E). 4. Details of Family Sl. 2008 9. Kolkata700001. Medical Cell. Signature of the Pension Sanctioning Authority/ Competent Authority . He is requested to discontinue the drawal of regular medical relief in respect of Shri/ Smt ____________________________ with effect from 1st day of _____________ (Month). Treasury Buildings. if any : Signature of the Pension Sanctioning Authority/ Competent Authority Copy forwarded for information and necessary action to: 1. 4. Name of Bank with account no. Writers’ Buildings. 2. The Treasury Officer ___________________________________ Treasury ________________________________________________________ (address). West Bengal. Finance (Audit) Department. The Branch Manager. 5.1. ___________________ ______________________________________________ / family pensioner) 2. Kolkata. ______________________________________ Bank _____________________________________________________ (address). 3. 3. 1. ________ (Year). Shri/ Smt _________________________________ (Ex. and address : (In case of Pensioners residing in Kolkata) 10.

2. Medical treatment done 7. 2008 FORM III Application Form for settlement of claim for reimbursement. : 5. 11.West Bengal Health Scheme. (i) OPD treatment : : : Private/Semi-Private/General Ward : Self or beneficiary (ii) Indoor treatment/ Day Care : 10. employee 8. (See sub-para (i) of para 11 of memo no. Full Address: (i) Office (from where retired)/ Pension Sanctioning Authority : : : (ii) Present Residence : 4. Accommodation Category (Put tick mark) 9. Name of the Hospital with address & code no.f. Identification No. treatment 11.D. Disease : : : .05. Full name of Govt. Name of the beneficiary & relationship with the Ex-Govt. Period of O.09.e. Enrolment under the Health Scheme w. Pensioner / Family Pensioner (in Block letters) 3. Last Pay Drawn (Band Pay + Grade Pay)/ Basic Pension : 6.P. Period of indoor treatment 12.) (To be filled in by the applicant) 1. 3475 F dt.

West Bengal Health Scheme. 15. I am a beneficiary of the West Bengal Health Scheme. Hospital) (i) Amount sanctioned (ii) Order no. 2008 13. Pensioner / Family Pensioner . : : : : : : : Declaration 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 expenses were incurred is wholly dependent on me. 2008.D. Total amount claimed – (i) OPD treatment (ii) Indoor treatment 14. Date: Signature of Govt. and card issued under the scheme was valid at the time of treatment.O. and date (iii) Sanctioning Authority (iv) D. I agree for the reimbursement as is admissible under the rules. Details of permission (i) For treatment in Speciality Hospital outside the : State (ii) For human organ transplantation/ ICD/ CRT/ Dual Chamber Pacemaker/ more than two drug eluting stents. if any (only for treatment in Govt. Details of Medical advance. etc.

(a) (b) Description of items Consultation fees (indicate total no. Pensioner/ Pension Sanctioning Authority : 3.) Medicines (give details of purchase in separate annexure. of original bills & vouchers (V) Amount claimed for OPD treatment : : Sl. if required. Details of expenditure: (I) Name of the diagnosed disease ( vide list enclosed) * : (II) Name & Code No. : 4. of consultations) Pathological Investigations (give Break-up in a separate annexure with code no. No. : 2. Name of the Govt. 3475 F dt. Name & address of Office of the Ex-Govt.) Radiological investigations (attach separate list.West Bengal Health Scheme. 11.05. of the empanelled/ recognised Hospital : (III) Period of OPD treatment : (IV) Total No. pensioner/ family pensioner with identification No. and clause-7 (1) of the Health Scheme] 1. 2008 FORM “IV1 ” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for OPD Treatment [See sub-para (ii) of para 11 of the memo no. if required) Amount Claimed Amount admissible (for official use) (c) (d) . employee/ Govt. employee & identification No. relationship with Ex-Govt. Name of the patient. with code no.09.

(viii) Renal failure.__________________________ was/ has been suffering from___________________as listed in Sl. (ix) Thallasaemia/Bleeding disorders/Platelet disorders. 797-F (MED). Sri/Smt. 2008 (e) Special devices like hearing aid/artificial appliances etc. (specify) (f) Miscellaneous (specify) Total (Rupees: only) (Signature of Claimant) Name in Block Letters Address: 1. No. Certified that the patient.West Bengal Health Scheme. dated 31-01-2011] . 2008 (i) Malignant diseases. 2008 and the expenditures shown above are correct and the treatment services prescribed and provided were essential and minimum that required for the recovery of the patient. (iii) Hepatitis B/C and other liver diseases. (v) Heart diseases. (xi)None of the above list (Specify name of the ailment) [vide Para-10 of Memo No. 2. (iv) Insulin-dependent diabetes. Counter signed by (Signature of the Treating Specialist with official seal) Administrative officer/Medical Superintendent of the recognized Hospital with official seal * OPD Disease List as per clause –7(1) of the WBHS. (vi) Neurological disorders/Cerebrovascular disorders. (x) Injuries caused by accidents. (vii) Malignant malaria. Certified that the relevant bills/vouchers have been verified by me in pursuance of the latest approved rates of the WBHS. (ii) Tuberculosis.__________________ of the WBHS OPD list below*.

Employee/ Pension Sanctioning Authority : 2. Code No. Clause6. Name & address of Office of the Ex-Govt. Pensioner/family pensioner with identification No.5. if necessary) Total=Rupees .09.West Bengal Health Scheme. (3) Amount Claimed (Rupees) (4) (iii) (iv) (v) Miscellaneous (Specify & give details in separate sheet. relationship with Ex-Govt. of original bills & vouchers : : (V) Details of Amount claimed (A) for Package treatment from ________ to ________: Amount admissible (Rupees) (for official use) (5) Sl No. Name of the patient. & Class of the empanelled/ recognised Hospital : : (III) Period of Indoor/Day Care treatment (IV) Total No.3475-F Dt. (1) (i) (ii) Procedure Name (2) Procedure Code No. Clause-7 (2)] 1. Employee & identification No. 2008 FORM “IV2” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for Indoor/Day Care Treatment and related OPD treatment [See Para-5 of Memo. No. : 3. Details of expenditure: (I) Name of the diagnosed disease (II) Name.11. Name of the Govt. : 4.

(1) (i) Description of items (2) Room Rent : (a) Ward (b)ICU/ITU/CCU/NICU/PICU (c) HDU/ Step Down Unit/ Burn Unit Charges for : (give details with code nos. (1) (i) (ii) Description of Items (2) Consultation fees (indicate total no. 2008 (B) for Non-Package treatment from __________ to ___________ Amount claimed (Rupees) (4) Amount Admissible (Rupees) (for official use) (5) Sl. No. in separate annexure) (a) Indoor visit of specialist/ super specialist Item Code (3) (ii) (b) Radiological Investigations (c) Pathological Investigations (d) Medicines (e) Artificial devices (f) Miscellaneous (specify) Total : =Rupees (VI) Related OPD treatment in terms of Clause-9 or Clause-7(2) Amount Claimed (3) Amount admissible (for official use) (4) Sl. in separate annexure) (a) Pathological investigations .West Bengal Health Scheme. No. of consultations) Charges for: (give details with code nos.

. Certified that the services of Special Nurse/Ayah were required from ________________ to ______________ that were absolutely essential for the recovery of the patient.…………......... Conservative treatment of ___________________________________ (Disease) done from ______________ to ________________....... Specific procedure/Operation performed was ___________________________ on _________________ 4. Grand Total (package + non-package+ OPD amount) (Rupees: (in words) =Rupees only) (Signature of Claimant) Name in Block Letters Address: 1. 2008 (1) (b) (2) Radiological investigations (3) (4) (c) (d) Medicines Special devices like hearing aid/artificial appliances etc. (Signature of the Treating Specialist with official seal) Countersigned by Medical Superintendent/ Administrative officer of the recognized Hospital with seal ... Certified that the relevant bills/vouchers have been verified by me as per latest approved rates of the WBHS..... 3..West Bengal Health Scheme... 2008 and the expenditures shown above are correct and the treatment services provided were essential and minimum that required for the recovery of the patient.. (specify) Miscellaneous (specify) (e) Total: =Rupees ...... 2.... ....

Employee & identification No.2011] 1. 797-F (MED). employee/ Pension Sanctioning Authority : 2. : 3. Name of the Govt. dt. Details of expenditure: (I) Name of the disease (* vide list enclosed) Name & Address of the Hospital : 4. No. : (II) : (III) Period of treatment (IV) Total No. pensioner/family pensioner with identification No.West Bengal Health Scheme. relationship with Ex-Govt. of original vouchers Details of Amount claimed: (give details in separate annexure. Name & address of Office of the Ex-Govt. 2008 FORM “IV3 ” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for treatment services taken from WB Health Scheme non-recognised Private Hospital/ Nursing Home [See Para-23 of the FD memo no. _______ (1) (i) (ii) (iv) (v) Description of items (* vide list enclosed) (2) Treatment Period (3) Amount claimed (Rupees) (4) Amount Admissible (60% of approved Package rate) (Rupees) (for official use) (5) Total= Rupees (Rupees : (in words) ______________ ________________ only) (Signature of Claimant) Name in Block Letters Address: . 31. Name of the patient.01. if required) : : Sl.

3. (e) Removal of foreign body on emergency basis.West Bengal Health Scheme. (b) Acute Appendicitis operation on emergency basis. 31-01-2011 (a) Accidental injury. Countersigned by Medical Superintendent/ Administrative officer of the Private Hospital/ Nursing Home with seal (Signature of the Treating Specialist with official seal) *List as per Para 23 of Memo No. dt. Certified that the relevant bills/vouchers have been verified by me and the expenditure shown is correct and the treatment services provided were essential and minimum that was required for the recovery/stabilization of the patient. is____________________ and is valid up to ____________. 797-F (MED). Certified that the patient had been admitted under my care at _________________Hospital/Nursing Home as an emergency case. Certified that the treatment was done in an organization that has a License under the West Bengal Clinical Establishment Act and Rules and the licence no. The Specific procedure/Operation performed was ___________________________________________ on __________________ 2. 2008 1. (d) Haemodialysis. . (c) Delivery on emergency basis.

] 1. 796-F (MED). 2008 FORM V Checklist For Reimbursement of Medical Claims [See sub-para (ii) of para 11 of memo no. Whether claim is for pensioner/family pensioner himself or his beneficiary. Entitlement of accommodation (Put tick mark) 6. mention – a) Name of the beneficiary and relationship with pensioner b) Beneficiary’s Identification No.05. 3475 F dt. (a) Name of office with address (b) Directorate (c) Department : : : : : 4. etc. Period of treatment: a) OPD b) Indoor/Day Care treatment 10. Yes/No. a)Treatment done within the State(i) Copy of intimation letter furnished : : : : : Private/Semi-Private/General ward : : : Yes/No : : from ________ to__________ from ________ to__________ : : : : Yes/No. Details of advance sanctioned (if any) a) Amount b) Order No. Disease 7. if for his beneficiary.09.) (Vide Para-8 & 9 of Finance Deptt. Notification No. c) Validity of the Card upto 5. Pensioner’s/Family Pensioner’s Identification No. . dated 31-01-2011) b) Treatment done outside the State – Copy of permission letter furnished : Yes/No. Whether treatment was done in non-empanelled hospital If yes – a) Name of the hospital/nursing home with Clinical Establishment licence No. and address 9. 11. (ii)Copy of permission letter furnished : (For human organ implantation/ Dual-chamber pacemaker/ AICD/ CRT/ more than one drug eluting stents Implantation.West Bengal Health Scheme. & date c) Sanctioning Authority 11. Name of the hospital where treatment was done/ to be done/ is going on 8. Full name & designation (block letters) 3. & date of enrolment 2.

. Yes/No... Yes/No. Yes/No Yes/No.... : : : Yes/No... The following documents are submitted (please tick [√] the relevant column)-(a) Photocopy of the Health Scheme identity Card of I) Govt. Signature of the Applicant . Yes/No. Dated.... Yes/No Yes/No (b) Essentiality Certificate (as specified) (c) Copy of discharge certificate (d) Copy of OPD prescription (e) Total Number of original bills & cash memos/ money receipts (f) Detailed list/Statement of medicines furnished (g) Detailed list of investigations furnished (h) Original papers have been lost the following documents are submitted(I) Photocopies of claim paper (II) Affidavit on stamp paper (III) Photo copy of Police Diary (i) In case of death of Govt.. Yes/No. Yes/No... Yes/No............ Yes/No. (a) Whether the claim for reimbursement has been preferred within (i) three months from the date of discharge of indoor treatment (ii) three months from the date of consultation of OPD treatment (iii) three months from the date of purchase of medicines. 2008 12. etc. whether delay in preferring claim has been condoned by the West Bengal Health Scheme Authority under the Finance Department 13. (for continuous OPD treatment) (b) If not. Pensioner/family pensioner II) Beneficiary : : : : : : : : : : : : Yes/No..West Bengal Health Scheme..... Pensioner/ Family Pensioner following documents are submitted(I) Affidavit on stamp paper by claimant (II) No objection from other legal heirs on stamp papers (III) Copy of death certificate : : : Yes/No.

9. 3.P. 1. No. 4.05. 2. No. 5. 5. recognised under the West Bengal Health Scheme. 8. if any Photograph (Stamp size) Name Age Relationship 2. 6. 3. Name of the Govt. 7. Sl. Pensioner/ Family Pensioner Pensioner Identification No. (P. 3475-F dt. No.P. 2008 with effect from __________________ He/She and his/her family members are entitled to the medical attendance and treatment in a Government Hospital/empanelled Private Hospital or Institution etc.* Signature of Pension Sanctioning authority /Competent Authority.West Bengal Health Scheme. 5. 2008 FORM. No. 11.O.VI Temporary Family Permit [See sub-para (vii) of para-7 of memo no. 2008 in the entitled class mentioned in Sl.O.) Last designation Last Pay (Band Pay + Grade Pay)/ Basic Pension Entitlement of accommodation Date of Birth Date of retirement/ death Residential address Details of Family : : : : : : : : : Monthly income. Shri/Smt. ______________________________________________ last attached to _____________________________________________________________________ (office) under ________________________________________ Department/ family pensioner has been enrolled under the West Bengal Health Scheme. *Strike out whichever is not applicable. This permit is valid for 6 (six) months from the date of enrolment*. The temporary family permit is valid till the Government pensioner/ family pensioner gets P. .09] 1. 4.