SARVODAYA (CO-ED) VIDYALAYA NO 1,

Shakti Nagar, Delhi-110007

Phone: 23841621 email: svno1shaktinagar1207037@gmail.com Sch ID 1207037

Employee Name & Designation BABU LAL

Name of Hospital, Panel/Non Panel (With Saroj Medical Institute (panel)139
DGEHS Sr No)
Name of DGEHS Card Holder & Designation BABU LAL (TGT )
DGEHS Card No & Entitlement 255037. SEMI PRIVATE
Date of Submission of Bill 18/10/2022
Date of First OPD 08-06-2021
Claiming Period 08/06/2021 TO 19/04/2022
Patient Name & Relation DEEPAKSHI YADAV (DAUGHTER)
Certified that: 1) The said medical bills enclosed herewith are as per DGEHS norms terms and
conditions along with DGEHS restricted sheet is as under:-

Summary Details of Medical Claim Bill

Name & Designation of Beneficiary BABU LAL (TGT)
Patient Name & Relationship DEEPAKSHI YADAV (DAUGHTER)
DGEHS Card No. 255037
Name of the School SARVODAYA (CO-ED) VIDYALAYA NO 1,
Shakti Nagar, Delhi-110007
Cash Dated Name of Medicines/Test/ Name of Actual Bill Charged By Restricted DGHS
Mem Patient & Treatment Hospital/Lab/Drug Hospital/Test/Medicines as per Code
o No. Relationship Store DGHS
Rate List

FRT/ 08/06/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01

21- 2021 YADAV INSTITUTE
22/11 (DAUGHTER
00910 )
7
FRT/ 13/07 DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
01380 )
0
FRT/ 13/07 DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- /2021 YADAV INSTITUTE
22/00 (DAUGHTER
01377 )
8
FRT/ 07/09/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
02194 )
1
FRT/ 07/09/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
02190 )
3
FRT/ 19/10/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
02823 )
2
FRT/ 23/11/ DEEPAKSHI Test (P/S FOR ANAEMIA) SAROJ MEDICAL 135 135 1394
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03346 )
5
FRT/ 23/11/ DEEPAKSHI TEST (HAEMOGRAM. SAROJ MEDICAL 135 135 1394
21- 2021 YADAV CBC ) INSTITUTE
22/00 (DAUGHTER
03346 )
5
FRT/ 23/11/ DEEPAKSHI TEST (CRP) SAROJ MEDICAL 100 100 1458
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03346 )
5
FRT/ 23/11/ DEEPAKSHI TSH(TEST) SAROJ MEDICAL 90 90 1562
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03346 )
5
FRT/ 23/11/ DEEPAKSHI VITAMIN D (TEST) SAROJ MEDICAL 550 550 1552
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03346 )
5
FRT/ 23/11/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03345 )
9
FRT/ 26/11/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03387 )
9
FRT/ 26/11/ DEEPAKSHI Test (urin c/s) SAROJ MEDICAL 200 200 1739
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03391 )
0
FRT/ 26/11/ DEEPAKSHI Test (urin r/m) SAROJ MEDICAL 35 35 1383
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03391 )
0
FRT/ 03/12/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03488 )
9
FRT/ 07/12/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2021 YADAV INSTITUTE
22/00 (DAUGHTER
03528 )
9
FRT/ 05/01/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
21- 2022 YADAV INSTITUTE
22/00 (DAUGHTER
04058 )
6
FRT/ 19/04/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
22- 2022 YADAV INSTITUTE
23/00 (DAUGHTER
00209 )
9
FRT/ 21/06/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
22- 2022 YADAV INSTITUTE
23/00 (DAUGHTER
01075 )
0
FRT/ 02/08/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
22- 2022 YADAV INSTITUTE
23/00 (DAUGHTER
01673 )
7
1369 03/08/ DEEPAKSHI MEDICINE SAROJ MEDICAL 508 508 NA
2022 YADAV INSTITUTE
(DAUGHTER
)
FRT/ 30/08/ DEEPAKSHI OPD CARD SAROJ MEDICAL 150 150 01
22- 2022 YADAV INSTITUTE
23/00 (DAUGHTER
02056 )
8
Total 3943.00 3943.00

2) All medicines provided to the patient are not food supplement vitamin and calcium nature (As per O.M. No
DGHS-16012/19/2016-DGEHS CLD OKD, Cancer patient who may be permitted vitamins, minerals., food
supplement and antioxidants if the same has not prescribed by the concerned specialist essential for
therapists use with proper diagnostic and justification concerned HOS should also furnish an undertaking to
this effect along with each claim).
 3) The treatment given to the patient is not cosmetic nature.
4) The said medicine reimbursement bill has submitted on time i.e. within six months as per CCS (MA) Rules.
5) IPD (Admit) Case all original Receipts of Payment to Hospital, Discharge Summary, Emergency Certificate,
Self Explanatory Letter of Employee, Final Bill, Final Bill Detailed and calculation sheet (Claim restricted as per
DGEHS (Non-NABH/NABH) Rates with DGEHS Code)
6) This is certified that the said medical reimbursement bill has been checked and found correct as per the
DGEHS norms, terms & Conditions and also restricted as per the DGEHS Rates along with mentioning
DGEHS S No/Code.

DELHI GOVERNMENT EMPLOYEES HEALTH SCHEME

REVISED MEDICAL 2004 FORM FOR REIMBURSEMENT OF
MEDICAL CLAIMS OF DGEHS BENEFICIARIES
(To be filled by the claimant)
1 DGEHS Card No. and place of Issue : 255037. GBSSS NO 1 SHAKTI NAGAR
Directorate of Education, Delhi
2 Validity of DGEHS Card From 19/09/2019 To 31/07/2041
3 Ward Entitlement (If Admitted in Hospital) : Semi Pvt

4 Full name of Employee/Beneficiary : BABU LAL

(Block Letters)
5 Full address: : 74 MCD QUARTERS NIMRI COLONY
ASHOK VIHAR DELHI 110052.
6 Telephone No. : (O) (R)
9910846251
7 E-mail address, if any : blyadav81.gmail.com
8 Name of the Bank: PNB ACCOUNT NO- 51522413000207 Branch: KIRODIMAL
COLLEGE DU Branch MICR CODE -110024653 IFS Code:PUNB0515210
Telephone No. of Bank Branch 01128044907

9. Name of the patient & Relationship : DEEPAKSHI YADAV (DAUGHTER)

with the card holder :

10. Basic Pay (excluding grade Pay) : 58600

11. Name of the Hospital with Address: : Saroj medical institute

Add- 8&9 pocket 8B sector19 rohini delhi
a) OPD treatment (Investigations) : Yes
& period of treatment. : 08/06/2021 TO 19/04/2022
b) Indoor Treatment. :
12 Total Amount Claimed : Rs 3943.00

Total Amount Claimed Consultatio Investigatio Medicine Other

n Charges n Charges Charges Charges
For OPD 3943.00 2250.00 1245.00 508 00
Treatment
For Indoor
Treatment
13 Details of referral : Prescription Attached yes

14 Details of Medical advance, if any :

DECLARATION
I hereby declare that 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. I am a DGEHS beneficiary and the DGEHS Card was valid at the time
of treatment. I agree for the reimbursement as is admissible under the rules.

Signature of DGEHS holder

Dated:
Note: Misuse of DGEHS facilities is a criminal offence. Suitable action including
cancellation of DGEHS Card shall be taken in case of willful suppression of
facts or submission of false statements. Suitable disciplinary action shall be
taken in case of serving employees.
 DELHI GOVERNMENT EMPLOYEES HEALTH SCHEME
REVISED MEDICAL 2004 FORM FOR REIMBURSEMENT OF
MEDICAL CLAIMS OF DGEHS BENEFICIARIES
(To be filled by the claimant)

1 DGEHS Card No. and place of Issue : 255037 GBSSS NO1 SHAKTI NAGAR
Directorate of Education, Delhi

2 Validity of DGEHS Card From 19/09/2019 To 31/07/2041

3 Entitlement (If Admitted in Hospital) Semi Pvt

4 Full name of Employee/Beneficiary : BABU LAL

(Block Letters)
5 Designation : TGT

6 The following documents are submitted (Please tick (√) the relevant column)
(a) Revised Medical 2004 Form : √Yes/No
(b) Photocopy(s) of DGEHS Card showing validity : √Yes/No
(c) Copy of referral/authorization form from AMA : Yes/√No
(d) Original Bills : √Yes/No
(e) Copy of prescription for OPD cases/Discharge
Summary for indoors Cases : √Yes/No
(f) Breakup for lab investigations : √Yes/No
(g) Breakup of drugs prescribed : √Yes/No
(h) Emergency certificate from hospital empanelled/registered with
Government in case of emergency admission : Yes/√No

(i) Self explanatory letter showing the need

of emergency visit (in emergency case) : Yes/√No
(j) Non availability certificate form AMA (attached dispensary/Hospital)
for drugs prescribed in OPDs : √Yes/No
(k) Original papers have been lost the following
Documents are submitted: -
i) Photocopies of claim papers : Yes/√No
ii) Affidavit on Stamp Papers : Yes/√No
(l) Incase of death of Card Holder the following documents are submitted: -
i) Affidavit on Stamp papers by claimant : Yes/√No
ii) No Objection from other legal heirs on Stamp Paper: Yes/√No
iii) Copy of death Certificate : Yes/√No
7 Name of the Bank PNB ACCOUNT NO. 51522413000207. Branch:
KIRODIMAL COLLEGE DUBranch MICR Code:110024653 IFS Code:
PUNB0515210 Telephone No. of Bank Branch. 01128044907

Signature of DGEHS holder

Tel. No. (O)
(R)
e-mail Address:

Dated:
1. Kindly enclose photocopy of cancelled cheque for online transfer of many to
the account of beneficiary.
2. Provide one original copy and two photocopies of complete set claim.