lication Form

rrsement for cost of tn-Patient Department (lPD) treatment in Non-Empanelled

under West Bengal Health Scheme

(Appticable for those who ore not oble to cloim through online by himself/herself ond online entry sholl
hove to be done by the office of Heod of Office)

I3.!-!L!llJ-E r'41!Y.!-lLl3ilYLl-l
1. D"trlit E*pl"r/""/P"*i"*"
Full Name
"f HRMS lD / PPO No.
(in Block letters) iytowrq furr{
Enrollment lD No.
,
urb/4..P / r7f-t,olFo
./+4 (hg
Claim Application lD
(To be filled ot the time
online entry from end the
of

Head of Office)
1-ailil;itiatieni, rffitinE*ospital ano condonation nequiremenfif.iny , ,'.-'
2.1 Name of Patient gJ t 1"f, 4n n"y+*
2.2 Name of Non-Empanelled/hospital where treatment 1r'rrs& fiErLo ftt frLlf. P/f:
was availed.
2.3 Requirement of approval of delay Condonation, if YesE NoEI' Not knownn
__r_t::-]ffi
Any (Tick mark in appropriate box)
,r 13. Arrtn 'oyee or pensioner or
family pensioner)
"f "*pl
Sl. No. I Name of claimant Relation
3.1

4. Period of treatment
Admission Date 2.? /oj /2oal Discharse Date Bl/ot,lOa21
5.Type of Discharge
Sl. No. Type of Discharge Tick mark in Sl, No. Type of Discharge Tick mark in
appropriate box appropriate box
5.1 Normal g- 5.3 Refe rra I tr
5.2 Risk Bond tr 5.4 Death n
5.Amo unt Clai medt fo-i:i,
Sl. No. Type of Treatment Tick mark in
appropriate box
6.L Only Procedura l/ Package Treatment tr
6.2 Only Non- Procedural/ Package Treatment U
6.3 Both Procedural/ Package and Non- Procedural/ Package Treatment tr

Period of Procedural/ Packaee Treatment From I To

Sl. No Name of Procedures/ Packages Amount Claimed
(Rs.)
6.1..L (/ AC- I L tzs-o'l-
6.L.2 J
n n{**a-l 1: Clour,<- d--a*o;
6.1.3 / t-.

6.1..4 \
 ,-
!-

I ine Reimb icat rm

6.1.5
Total LL, A7W*

Sl. No. Name of lmplants Amount Claimed

(Rs.)

6.2.t
6.2.2
6.2.3
6.2.4
Total

Period of Non-Proc"a*y pr.t f*atment f ro*

"g" Name of Components Amount Claimed
Sl. No.
( Rs.)

-.a's.t m/ Bed Rent f) ,^, [-/r'i^-

/rulrcu/r,rrcu/prcu rl.o* ,;L7l09lzl to i'lc '':s
tl tr4,-ttl'
HDU/SDU From To

Burn Unit From To

CRIB From To

G enera l/Sem i-Private/Private From To

/6.3.2 Consultation Fees 2 fr7e€/'

"A
-'6.3.3 Patholoeical and Radioloeical lnvestigations [-o-..t/'
6.3.4 Medicines
6.3.5 Consumables
6.3.5 Special Nu rsing/Aya Charges
6.3.7 Miscellaneous. (lf Any Specify)
Total g, q5 o-ol2

No. ofVouchers
*-.7 otalTreatment Cost [6. L+ 6. 2+6.3] u%5 /,*f'

ln words; Rupees

I hereby declare that the statements made in the application of claim for reimbursement is true to
the best of my knowledge and belief. The person, for whom medical expenses are incurred, is a beneficrary
of West Bengal Health Scheme and possessed a valid enrollment cerlificate at the time treatment. I will be
personally responsible and liable for any disciplinary action taken against me in terms of WBS (CCA) Rules
L97L if the claim finds false and malafide due to any suppression of facts. I am enclosing the following
instruments to substantiate my claim in sequential manner.

Name/Particulars of enclosures to be attached Enclosed or not

 Manua rsement A
No.
1 Annexure-ll duly signed with proper stamp by the Medical Yes E Notr
Superintendent of a Non-Empanelled Hospital
2 Enrollment Certificate of beneficiary Yes tr Non
3 BillSummary Yes tr Notr
4 Money Receipts in sequentially Yes n Non
5 Copy of Discharge Summary (Case summary in case of death) and OT Yes tr Non
note and copv of death certificate
R Detailed Bill Yes I Non
7 Original copy of Voucher/ Tax lnvoice/ Challan of lmplants Yes a NoD
8 Copy of all investigation/ test reports in sequentially Yes tr Notr
9 Copy of OT Note in of procedural/package treatment and
case Yes tr Notr
treatment summary or bed head ticket in case of non-
procedu rallpackage treatment
10 ln case of death of Employee, Pensioner and Family Pensioner;
a. An affidavit on stamp paper by claimant Yes tr Notr
b. No objection from other legal heirs on stamp papers Yes I Notr
c. Copv of death certificate Yes E Notr
1.1 Filled ECS mandate form in case of those, whose bank details is not Yes n Notr
available in IFMS (in case of first claim only)
L2 Any other instruments (Specify) Yes tr Notr

Date: /./
--'
Signature of the Employee/Pensioner, /Claimant:
Name in Block Letters
Designation/Last Designation :
Certification of Medical Superintendent/ Administrative Officer and Treating Specialist of treating in
Non-Empanelled Hospital for claiming reimbursement of only "lndoor" treatment under WBHS

t. certified that the patient, srits^t. Z:rilt P 4*l ?/A is a

beneficia Bengal Health Scheme having
IS availed indoor'.reatment from Q-f/ o J,
that the Home/Health Care Organisation 6as
nos. of bed.
3, Certified that the Hospital/Nursing Home/Health Care Organisation obtai.ned a License under the
West Bengal Clipical Establishment Act and Rules bearing no, A7,jrl.9tf'2 and this License is
vatid up t" O6/O;lW2*l

Datet Q{qf 04f ,r-o z1

Hospital
Official Seal of the Hospital