No. W.

11036139 1201 7-RAN

Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
+>Fr<**

New Delhi, dated the Itt February, 2019.

Office Memorandum

Subject: Guidelines regarding implementation of Umbrella Scheme of Rashtriya Arogya Nidhi

(RAN).

The undersigned is directed to say that Rashtriya Arogya Nidhi (RAN) Society was set

up in 1997 to provide financial assistance to patients, living below poverty line and who are

suffering from major life threatening diseases, to receive medical treatment at any of the super
specialty Govemment hospitals / institutes. In its meeting held on 7.8.2018, the Managing

Committee of the RAN Society has decided, inter alia, that the Society shall be closed w.e.f.
1.1.2019. Accordingly the function of the RAN Society will now vest in the Department of Health
and Family Welfare w.e.f. 1.1.2019 and RAN scheme including Health Minister's Cancer Patients

Fund will be implemented by the Department of Health and Family Welfare.

2. To provide financial assistance to poor patients a new Umbrella Scheme of Rashtriya

Arogya Nidhi has been formulated with the approval of the competent authority. The Umbrella
Scheme of Rashtriya Arogya Nidhi (RAN) will have three components namely (i) Rashtriya

Arogya Nidhi (RAN), (ii) Health Minister's Cancer Patients Fund (HMCPF) and (iii) Scheme for

financial assistance for patients suffering from specified rare diseases. A copy ofguidelines ofthe
new Umbrella Scheme is enclosed for information and necessary action.

Under secretary to the

4u
o",.Jti/Y1tr'
Tel: 23061986
To

1. All the Govemment hospitals (as per list enclosed).

2. All Regional Cancer Centres (as per list enclosed).
3. All State Cancer Institutes and Tertiary Cancer Care Centres (As per list enclosed).
. 4. Health Secretaries of all State Govemments/UT Administrations.

Copy to:

1. Finance Division.
2. Under Secretary (PH/RD).
3. Director (Budget).
Copy for information to :

l. PS to HFM.
2. PS to MoS (AKC).
3. PS ro MoS (AP).
4. Sr. PPS to SecretarY (HFW).
5. Sr. PS to AS&FA.
6. Sr. PS to AS (Health).
7. Sr. PS to AS&MD.
8. PS to Addl. DG (AKG).
9. Sr. PS to JS (Rare Diseases).
10. Sr. PS to EA (NS).
11. PS to CCA.
12. Addl. DDG (BRS).

0v
,*.r.d",V-
Iffi
Under Secretary to the Govemment of
Tel:23061986
 tation o aN
(RAN).

The umbrella scheme of Rashtriya Arogya Nidhi (RAN) will have

three components
Patients Fund (HMCPF)
namely (i) Rashtriya Arogya Nidhi (RAN), (ii) Health Minister's cancer
and (iii) Scheme for financial assistance for patients suffering from specified rare diseases'

given below:
2. The objectives of the three components of the RAN Scheme are

(a) Rashtriya ArogyaNidhi- to provide financial assistance to poor patients living

relating to
below threshold poverty line and suffering from life threatening diseases
heart, kidney, liver, etc for their treatment at Government hospitals/institutes having

super sPecialtY facilities.

poor
(b) Heatth Ministerrs Cancer Patient Fund - to provide financial assistance to
patients living below threshold poverty line and suffering from cancer'
for their
Centres (TCCC)
treatment at Regional Cancer Centres (RCCs)iTertiary Care Cancer
and State Cancer Institutes (SCD.

(c) Financial assistance Scheme for poor patients suffering from rare diseases - to
provide financial assistance to poor patients living below threshold poverty line
and

suffering from specified lare diseases for their treatment at Govemment

hospitals/institutes having super specialty facilities'
Scheme of RAN
3. Details of guidelines and procedures for implementation of the Umbrella

are as under.

General conditions governing the Umbrella Scheme of RAN are as

under:
4.

(i) Financial assistance will be provided to poor patients living below StateAJT-wise
threshold poverty line as per Annexure-I'
of RAN is at
(ii) List of diseases covered for financial assistance under the Umbrella Scheme
Annexure-Il.
(iiD patients will be provided financial assistance for their treatment at Government hospitals
hospitals will not be eligible
having super specialty facitities. Those having treatment in private
for financial assistance under the scheme'
(iv) The financial assistance to eligible patients wilt be in the form of 'one-time grant''

(v) Government servants and their families will not be eligible under
this scheme'

(vi) There will be no reimbursement of expenditure already incurred'

Lq
'l
-t- u(4"9------"---
(vii) Families covered under Ayusman Bharat - Pradhan Mantri Jan Arogya Jojna (PMJAY)

will not be etigible for financial assistance under RAN and HMCPF components'
(viii) In a bid to speed up the assistance to the needy patients, Revolving Funds are set up in
Hospitals/Institutes listed at Annexure-Ill. Funds up to Rs. one crore for
each
Govemment
component separately (Rs. two crore in case of AIIMS, New Delhi for RAN
component only) will

be placed at their disPosal.

(ix) Powers are delegated to the Medical Superintendent/Director of the hospitals with

revolving funds for providing treatment up to Rs. 5 lakh for eligible patients in each case, out of
revolving fund.

(x) More hospitals shall be added in the list of hospitals with revolving fund as and when such
hospitals are identified by the Technical Committee.

(xi) Cases involving treatment beyond Rs. 5 lakh in hospitals with revolving fund and all the
cases for financial assistance from hospitals not having revolving fund will be referred to
Department of Health & Family Welfare, Govemment of India for approval'

(xii) Funds shall be released to hospitals not having revolving fund in respect of cases approved

by the Department of Health and Family Welfare along with the sanction letter'

(xiii) No separate funds will, however, be released to hospitals having revolving funds in respect
of cases received in and approved by Department of Health and Family welfare, involving
treatment beyond 5 lakh and such expenditure will be met out of the revolving funds.

(xiv) In case of hospitals having revolving fund, the cost of treatment in ail eligible cases will be
met out of the revolving fund, which will be replenished from time to time, on the basis of
utilization certihcate and list of beneficiaries furnished by the hospitals. On utilization of 7 5%o of
the amount placed in revolving fund, hospitals will become eligible for replenishment.

(xv) Maximum financial assistance admissible under the Scheme will be Rs. 15 lakh.

(xvi) Financial assistance received under Prime Minister's National Reiief Fund (PMNM) or
from any other source by the patient for treatment, shall be deducted from the admissible amount of
financial assistance under the Umbrella Scheme of RAN.

(xvii) For RAN and HMCPF components, there will be a Technical Committee, which shall
advise the Govemment in technical matters such as enlisting of diseases covered under Umbrella

Scheme of RAN and identifi,ing Govemment hospitals/institutes for setting up of revolving funds'

for financial assistance received in the pepartment and giving their

-2-
examining requests
n
recommendations on any other matter of techlical nature' The composition of the Technical

Committee will be as under:

1. Addl. DGiAdviser, DGHS.

2. Joint Secretary/Economic Adviser concerned'
3. Medical Superintendent, Dr. RML Hospital, New Delhi'
4. HOD, CardiologY, AIIMS, New Delhi'
5. HOD, Haematology, AIIMS, New Delhi'
6. HOD, Medical Oncology, Safdarjung Hospital, New Delhi

to
(xviii) Experts in rare diseases will be associated with the above Technical Committee
advise the Government in matter listed at sub para xvii above, in respect ofrare diseases.

5. Conditions specific to Scheme for financial assistance for patients suffering

from specified rare

diseases

(i) The objective of this comporent is to provide financial assistance to poor patients living
StatefuT-wise threshold poverty line (Annexure-I) and suffering from specified
Rare
below
Diseases (Annexure-Il), to begin with, for their treatment at Government hospitals having super

specialty facilities.
(ii) The rare diseases specified in Annexure-Il are disorders identified based on availability of
treatment, reasonably proven clinical outcomes and cost effectiveness. The list of
specified rare

diseases for financial assistance under Rare Diseases component of Umbrella Scheme
of RAN will

be as suggested by the relevant Technical Committee.

(iiO Patients suffering from rare diseases as specified in Annexure-Il belonging to the socio-

economic categories that are eligible to be PMJAY beneficiaries will also be considered for
packages not covered under PMJAY.

Common application form has been prescribed (Annexure-IV) for submission ofrequest
for
6.
financial assistance under any of the component of the Umbrella Scheme of RAN. The
application

shall be signed by the treating doctor/Head of the Department and countersigned by

the Medical

Superintendent of the hospital concemed.

7. Application for financial assistance shall be submitted along with:

(D Income certificate (in originat) of the patienvparents/other major eaming members of the
family, indicating income from all sources, duly certified by the Block/Mandal Development
officer/Tehsildar/SDM/ Administrator/special officer of Municipal Boards/District officer'
(ii) A copy of the entire ration card along with its cover page, with details of all the family
members, issued by the Food and civil Supplies Department of the stateruT Govemment duly self

attested.

g. All Govemment hospitals, where revolving funds are set up under RAN as well as Rare

will open separate bank accounts for the two sub components and submit the

-z'
Diseases components,

L\"*---"-
 to them under the
bank details to the Ministry immediately so that funds could be transferred
Umbrella Scheme of RAN.
g. Similarty all27 Regional Cancer Centres, where revolving funds are set up
under HMCPF

component, will open a separate bank account for the purpose and submit
the bank details to the
Scheme of
Ministry immediately so that funds could be transferred to them under the Umbrella
RAN.

10. This has approval of the competent authority.

Enc: Annexure I to IV.

i t-"'(

4-
 Annexure-I

Rural and Urban w.e.f.

In Rupees

Per capita per month poverty line as Revised per capita threshold income per
fixed by erstwhile Planning month w.e.f. 1.1.2019 under Umbrella
Commission for 20tl-12 Scheme of Rashtriya ArgYa Nidhi

State/UT Rural Urban Rural Urban

1 160 r388
ALL India 816 1000
I191 1529
Andhra Pradesh 860 1009
Arunachal Pradesh 930 r060 t49s I 701

1 190 l 387
Assam 828 l 008
1134 1269
Bihar 778 923
738 849 1064 I 185
Chhattissarh
Delhi I145 lt34 t57t 1605

Goa 1 090 r134 l 668 r522

932 t1s2 1327 1 530

Guiarat
Haryana 1015 1169 1902 I 593

Himachal Pradesh 913 1064 1239 1467

J&K 891 988 1339 1391

748 974 l 09s 1349

Jharkhand
Karnataka 902 1089 r294 I 578
1484 1425
Kerala 1018 987
1126 13 88 1484
Maharashtra 967
1047 l 258
Madhya Pradesh 771 897

Manipur 1118 I 170 1850 r629

Meghalaya 888 1 154 1248 1 536

l 155 1488 1 500

Mizoram l 066

t210 1302 1916 1 808

Nasaland
1011 1 180
Odisha 69s 861
1881 1 838
Puducherry 1301 I 309
I 155 147 5 r563
Puniab I 054
905 002 1272 1411
Raiasthan 1

t407 1 808
Sikkim 930 1226
1266 r33I
TamilNadu 880 937
l 009
1264 r 395
Telangana 860
1191 1334
Tripura 798 920
1061 1327
Uttar Pradesh 768 941
'Uttarakhand 880 1 082 1208 141 5

1138 1 368
West Bengal 783 981

t>
For Andaman Nicobar Islands use threshold levels of TarnilNadu, for Dadra and Nagar Haveli and for
Daman and Diu use levels for Gujarat, and for Lakshadweep use levels for Kerala, for Chandigarh use
levels for Punjab.

5-
 Annexure-II

RAN component
Illustrative list of categories of treatment for financial assistance under
(T'his list is reviewed by the Technical Committee fiorn time to time )

1. Cardiolog-r'& Cardiac SurgerY:

I ) Pacemakers including cRT/Biventricular pacemaker

Z) Automatic lnplantaLle Caldiovertel Defibrillator (AICD) and Cornbo
clevices.
and
3) Co1o1ary Artery Disease including Diagnostic Clardiac Clatheterization
Coronary AngiograPhY.
4) lnteruentional procedure including Angioplasty. with or *'ithout Stents
(Bare rnetal Stents as rvell as Drug Eluting Stents) Rota-ablation, Balloon
Valvuloplasty.
5) ASD. VSD and PDA device closure'
6) peripheral Vascular Angioplasty including Carotid Angioplasty & Renal
Angioplasty, Aortic Surgery and Stent Grafting'
7) Coil Ernbolization and Vascular plugs'
g) Electrophysiological Studies (EPS) and Radio Frequency (RF) Ablation.
9) Cardio vascular sllrgery for Congenital and Acquired conditions
including C.A.B.G, Valve replacement etc.
10) Heart/Lung Transplantation.(ceiling cost may be upto CGHS rates)
11) Intra Aortic Balloon Pump flARP)'
l2jThrombolytic Thelapy for Acute Myocardial Infarction, Pulrnonary
Thromboembolism & Pro sthetic t'ah'e Thrombo sis'
13)IVC Filter

2. Cancer:

1) Radiation treatment of all kinils including Radio Ther:apy and

Gama Knife Surgery/GRTiMRT/Brach-r'therapy'

2) Anti-Calcer Chemotherapy r.vith supportive rnedication including

homronal therapy.
3 Bo1e Marrorv Transplantation- Allo,genic& Autologolls
)
4) Diagnostic Procedures- including PET scatt'
5) Surgery for operable malignant tumours'
3. Urologr,/1.{errhrology/Gastroenterologv/GI Surgetry :

1)Dialysis(BothHaenrodialysisaswellasPeritoneal)
2) Plasrnalpheresis in ABO incompatible douors
3) Continuous RRT in Acute Renal failure
perm
4) Vasculal-access consumables (AV Grafts, Catheters includirrg
catheters) for DialYsis'
5) Renal transplant-The ceiling cost nlay be upto GGHS rates.
6) USG guided PCNL and USG guided SPC'
Zj Uraooopic surgical procedures in urology inclucling CPE rvith
TURBT.CP-E with endoscopic catheterization, CPE witli clot evacuation.
8) Endoscopic strrgical procedures in Gi surgery'

9) Acute GI energelcies like Acute Pancreatitis. GI bleeding, Cholangitis,

peritonitis, Intestinal Obstruction, Biliar,v stricture. Acute Fulminant Hepatitis'
Hepatic Encephalopathy, Hepatic Abscess etc'
t 0j Liver Transplantation and Surgery for portal hypertension-
the ceiling cost
may be upto CGHS rates. ?, M
- G- {,r+
 4. Orthorredics:

1) Treatment of Trar-tmatic & Pathological Ftacture'*

2) Implants for joint replacement'{'+
3) Spinal tixatior-r implant.**

'konly Indigenous iniplar:rts for use in Fracture and Poly Trauma will be
permitted under the scheme.
*,FJustification for Non Indigenous Lnplants tvould be provided by the treating
doctor.

5. NeurosurgelT - Neurologl' :

1) Brain Tumours
2) Head injurY
3) Intracranial aneurysms & aneurysms of *'eek vessels.
4) Vascular Malfonnations of brain & spinal cord
5) SPinal Tumors
6) Degelerative iDern-velinating diseases of brain/spinal cord
7) CerebrosPinal Stroke
8) Status EPilePtics
9) Ivlovement Disorders
1 0) Neurological infections
(Acute/chronic)
1 1) Traumatic SPinal InjurY
12) Occlusive Vascular Disease of Brain
1 3) Guillain-barre syndrome

14)MyastlreniaGravisinCrisis(rrredicalandsurgical)
1 5) Acute Po lymyo sitiswithVentilatory Failure

16) Acute or Clu'oriic Autoimmune' Diseases

6. Endocrinologl' :

e.g'
1) Complications and sequel of diabetes i.vhich require one time treaflnent
etc..
Amputation or Renal Tlansplant or Retinal detachment, Glaucotra
2) GH deticiencY
3) Adrenal insufficiency (Acute/Chr:onic)
4) Cushing's Disease
5) E,docrine surgery rvith post surgical treatment tbr one year.
6) Metabolic Bone Disease/Renal Tubular Acidosis'
7. Mental Illness :

Any treatment requiring one time grant for melltal disorders including

1)Organic Psychosis (actrte/ chlonic)'

Z) Functionai psychosis i,cludi,g Schizoptu'enia. Bio-polar
Disorders, delusional disorclers and other acute polyrnorphic psychosis
)) Severe OCD. Son.iatoform disorders'
and Severe
4) Develgpmer-rtal disor:clers ilcigdilg Autisl-r spectrum disorders
Selyiviolal disorders during childhood.

W or"g;;*";,,r".,roir,u.hological assessments. IQ assesstnent, blood

ilrr"
tests like ,"ru,, Iithiurn ancl drug level of carbarnazepiue, valporate'
pherrytoin ancl any other similar meclications'
6) CStr studies screening lor substances abuse/toxicology'
8. Gynecologl':

uterine Arter.y Ernbolization tbl Post Patlum Flemorhage

9 Rarc Diseascs :

1. Disorders amenable to treatment with Hematopoietic Stem Cell

Transplantation (HSCT)

Lysosomal storage disorders in early stages for which Enzyme

replacement
i.
Leukodystrophy'
Therapy (ERT) i"s presently not avaiiable leg Metachromatic
(MPS) type I
Krabbe,s disease *d ,.r.r. form of Mucopolysaccharoidosis
within first 2 Years of age.
neurological signs'
ii. Adrenoleukodystrophylearly stages), before the onset of hard
iii. Immune deficiency aisoroerr S.r.r. Combined Immunodeficiency (SCID)'
"g-
chronic Granulomatous disease, wiskot Aldrich syndrome,etc
iv. Osteopetrosis
v. Fanconi Anemia
vi. Others to be decided on case to case basis
2. Disorders amenable to organ transplantation

i. Liver Transplantation -Metabolic Liver diseases and other Inborn Errors of

Metabolism (small molecule diseases)
i. Tyrosinemia (failure to respond io nitisinone therapy or have documented
evidence of malignant changes in hepatic tissue)
ii. Glycogen storag"e disorderi (GSD' I, III and IV due to poor carcinoma
metabolic
control, multiplJ liver adenomas, or high risk for Hepatocellualr
progressive liver
or evidence of substantial cirhosis or liver dysfunction or
failure,
iii. MSUD (Maple Syrup Urine Disease),
iv. Urea cYcle disorders,
v. Organic acidemias,
vi. Wilson's disease (Decompensated cirrhosis)
vii. Bile acid synthetic defects (Decompensated cirrhosis)
viii. CriglerNajjar TYPe 1,
ix. Alpha t antitrypiin deficiency (Decompensated cirrhosis)
-famitial
x. Progressive Intrahepatic cholestasis (PFlC)(Decompensated
cinhosis)
xi. Others to be decided - case to case basis

ii. Renal TransPlantation-

i. FabrY's disease,
ii.AutosomalrecessivePolycysticKidneyDisease(ARPKD),
iii. Autosomal dominant poiyrystic Kidney Disease (ADPKD)
iv. Others on case to case basis

-Rarely Methyl
iii) Patients requiring combined liver and kidney transplants
etc
Malonic aciduria may require combined liver & Kidney transplant)

10. Miscellaneous :

not
Any life saving procedr.rre/ any other major illness/tleatment/inter-ventiotl by
of IIAN and recomme'ded
covered uder- any of the components ot: Umbrella Scheme
the Tec.hnical Committee cotrlcl be consider:ed lbr financial
assistallce '

- 8, !' Y-,
 Annexure-III

Diseases comoonents of the Umbretla Scheme of RAN

1. AIIMS, NewDelhi
2. Dr. RML Hospital, New Delhi
3. Safdarjung Hospital, New Delhi.
4. Lady Hardinge Medical College & Smt. SK Hospital, New Delhi'
5. PGI, Chandigarh
6. JIPMER, Pudducherry
7. NIMHANS, Bangalore
8. SGPGIMS, Lucknow
9. CNCI, Kolkata
10. KGMC, Lucknow
11. NEIGRIHMS, Shillong
12. RIMS, Imphal.
13. SKIMS. Srinagar.
14. Sree Chitra Tirunal Institute of Medical sciences and Technology, Thiruvananthapuram.

comDonent
1. Kamala Nehru Memorial Hospital, Allahabad, Uttar Pradesh'
2. Chittaranjan National Cancer Institute, Kolkata, West Bengal
3. Kidwai Memorial Institute of Oncology, Bangalore, Kamataka'(SCD
4. Regional Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu' (SCI)
5. Acf,aryaHarihar Regional Cancer, Centre for Cancer Research
& Treatment'
Cuttack, Orissa.(SCI)
6. Regional Cancer Control Society, Shimla, Himachal Pradesh'
7. Caicer Hospital & Research Centre, Gwalior, Madhya Pradesh'
8. Dr. B.R.A. indian Rotary Cancer Institute, (AIIMS), New Delhi'
9. R.S.T. Hospital & Research Centre, Nagpur, Maharashtra'(TCCC)
10. Pt. J.N.M. Medical College, Raipur, Chhatisgarh'
I i. Post Graduate Institute of Medi"al Education & Research (PGlMER),chandigarh.
12. Sherl- Kashmir Institute of Medical Sciences, Soura, Srinagar'
13. Regional Institute of Medical Sciences, Manipur, Imphal'
14. Govt. Medical College & Associated Hospital, Bakshi Nagar,
Jammu'
15. Regional Cancer Centre, Thiruvananthapuram, Kerala
16. Gujarat Cancer Research Institute, Ahmadabad, Guj arat'
17. MNJ lnstitute of Oncology, Hyderabad, Andhra Pradesh'
(SCI)
18. Pondicherry Regional Cancer Society, JIPMER, Pondicherry'
19. Dr. B.B. Cancer Institute, Guwahati, Assam.
20. Tata Memorial Hospital, Mumbai, Maharashtra
21.Indira Gandhi Institute of Medical Sciences, Patna, Bihar' (SCI)
ii. e"fr*V"frfti Regional Cancer Trust & Research Institute (RCC)'
Bikaner,Raj ashtan.
post Graduate Institute of Medical
23. Regional iancer centre, pt. B.D.Sharma
Sciences, Rohtak, HarYana.
24. Civil Hospital, Aizawl, Mizoram. (TCCC)
(TCCC)
iS. S*;uy C*ani Post Graduate Institute of Medical Sciences, Lucknow'
Nadu'
26. Govemment Arignar Anna Memorial Cancer Hospital, Kancheepuram'Tamil
27. Cancer Hospital, Tripura, Agartala.(SCl)

-9- +Y"
 Annexure-fV

Minister's Discretionarv Grant ([IMDG)

(Please tick rnark (,i )

Rashtriya ArogyaNidhi
ffiScRT,TtoNARYGRANTS
U*ttt, Uinister's Cancer Patient Fund

Rare Diseases

I Na,ne of tne Patient (in Block Letters)

2 Age

) @-ernlanent Address along with Pin Code

(b) Address for corresPondence

4 (a) grnait Aadress (if available)

(b) Mobile No. (if available)

5 (a) Father's /Mother's name

(b) Husband/wife's name

6 Appticalrt's R"tattorship with the Patient

7 ffig (Nameofthedisease)

8
n whom the Patient
is dependent, is uu employee of Centre/State Government

9 N ll.familY members
from all sources issued by Tehsildar/BDO/SDO/
SDM/DC.
(Original lncome Certificate should be attached'
Ho*-.u.r, where online certificates are issued' self
attested coPY of inco
10 ffissistance required

11 ffis been received from (a)

H,"{ll,t
any Ministry/Depaftment other t!a1ftinisly :f
ful,"ify Weifare^such as Prime Minister National Relief
Fund or CM Relief Fund for treatment of the same
disease.

elfare earlier' Ifso' full

details rnay be given.
12 ffitheRationcard

- to -
ffi (Attach self attested coPY)

I hereby share my Aadhaar Nutnber issued by UIDAI &

voluntaiily give my consent to link rny Aadhaar Nurnber
with my request for financial assistance under
RAN/HMCPF/Rare Disease/HMDG Schernes' I
also

authorize Ministry of Health & Farnily Welfare

to use my
AuJnuu, card details & identity information for
authentication with tIP4l.

DECLARATION

L l declare that the information given above

is correct and complete in all respect'
(PMJAY)'
2. I am not covered for benefits under Pradhan Mantri Jan Arogya Yojna
OR
(For rare diseases)
pMJAy, the amount of financial assistance required, indicated at colurnn
10
Though I am covered under
above, is only for packages not covered under
PMJAY'

Signature of the ApplicanVPatient

Date :

ToBEFILLEDBYTHEM.o.INCI{ARGBoFTIIECASE/HoSPITALiETC!WHERETHE
IS RECEIV[NG
-PATIENT

No'
1. Name of the Patient & Hospital Registration

done
2. Gist of Reports of important Investigations

clinical
3. Diaguosis-A short Note on the present

conditions rnaY be indicated

4. Ifthe patient has been operated, please

lndicate the date ofoPeration

patient is
5.(a)The name of the Hospital where the

receiving treatment.

(b) Whether Hospital is Government or Private'

6. Arrount recommended for treatment

7. Probable date of operationiintervention

p,u
- lt- U ,{vr-.-
 in Column 6
8. Item wise break up of expenditure recommended

for Cost (In RuPees)

"a

g.CertifiedthatthepatientisnotcoveredforbenefitsunderPMJAY.
OR

(For rare diseases)

6 above' is only
recommended for treatment under column
For patients covered under PMJAY, the amount
fr packages not covered under PMJAY'

Signature of the HOD/MO-in-charge

Professor with offrcial Seal
(Note below the level of consultant/Asiistant

and belief'
above are true to the best of my knowledge
1. certified that the patient,s particulars given
are to be transferred
IFSC Code) of the hospital to.which funds
2. Details of Bank account (including
revolving funds have not been set up)'
(Bank details areto be provided in cases 1;;p't"it'wtreie
"f

tttl" Bank & Address

PAN/TIN/TAN
Dfrilffiftlre a"count holder- name of

Signature of the Medical Superint"l*nl?lth"

girpl"VVfedical Institution with Offi cial Seal

- tz- Pt>