Loading
Form preview picture

Get West Bengal Health Scheme Reimbursement Form For Pensioners

West Bengal Health Scheme 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. 3475 F dt. 11. 05. 09. and clause-7 1 of the Health Scheme Name of the Govt* pensioner / family pensioner with identification No* Name of Office of the Office of the Ex-Govt* employee / Govt* Pensioner / Pension Sanctioning Authority Name of the patient relationship with Ex-Govt* Employee Identification No* Details of expenditure I II Name Code No* of the empanelled / Govt* recognized Hospital III Period of OPD treatment IV Total No* of original bills vouchers V Sl* No* Name of the diagnosed disease vide list enclosed Amount claimed for OPD treatment Description of items a Consultation fees indicate total no. of consultations b Pathological investigations give Break-up in a separate annexure with code no. c Radiological investigations attach separate list if required with code no. d Medicines give details of purchase in separate annexure if required Rupees Amount admissible for official use e Special devices like hearing aid / artificial appliances etc* specify f Miscellaneous specify Total only Signature of Claimant Name in Block Letters Address 3. Certified that the relevant bills/vouchers have been verified by me in pursuance of the latest approved rates of the WBHS 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. fromas listed in Sl* No* of the WBHS OPD list below. 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 2008 i Malignant diseases ii Tuberculosis iii Hepatitis B/C and other liver diseases iv -dependent diabetes v Heart diseases vi Neurological disorders/Cerebrovascular disorders vii Malignant malaria viii Renal failure ix Thallasaemia/Bleeding disorders/Platelet disorders x Injuries caused by accidents. xi None of the above list Specify name of the ailment vide Para-10 of Memo No* 797-F MED dated 31-01-2011. See sub-para ii of para 11 of the memo no. 3475 F dt. 11. 05. 09. and clause-7 1 of the Health Scheme Name of the Govt* pensioner / family pensioner with identification No* Name of Office of the Office of the Ex-Govt* employee / Govt* Pensioner / Pension Sanctioning Authority Name of the patient relationship with Ex-Govt* Employee Identification No* Details of expenditure I II Name Code No* of the empanelled / Govt* recognized Hospital III Period of OPD treatment IV Total No* of original bills vouchers V Sl* No* Name of the diagnosed disease vide list enclosed Amount claimed for OPD treatment Description of items a Consultation fees indicate total no. of consultations b Pathological investigations give Break-up in a separate annexure with code no. c Radiological investigations attach separate list if required with code no.

How It Works

west bengal health scheme reimbursement form rating
4.8Satisfied
62 votes

Tips on how to fill out, edit and sign Essentiality online

How to fill out and sign Cerebrovascular online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Feel all the benefits of completing and submitting documents on the internet. With our solution completing West Bengal Health Scheme Reimbursement Form For Pensioners usually takes a couple of minutes. We make that possible through giving you access to our feature-rich editor capable of altering/correcting a document?s original textual content, inserting special boxes, and putting your signature on.

Fill out West Bengal Health Scheme Reimbursement Form For Pensioners in a couple of clicks by simply following the instructions below:

  1. Find the template you will need in the library of legal forms.
  2. Click on the Get form button to open it and move to editing.
  3. Fill in the necessary fields (they will be yellowish).
  4. The Signature Wizard will allow you to put your electronic signature as soon as you?ve finished imputing information.
  5. Insert the relevant date.
  6. Look through the entire form to make sure you?ve filled in all the data and no corrections are needed.
  7. Click Done and save the filled out document to the gadget.

Send the new West Bengal Health Scheme Reimbursement Form For Pensioners in an electronic form as soon as you finish filling it out. Your data is well-protected, as we keep to the newest security requirements. Join millions of happy users who are already filling in legal templates straight from their houses.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

West bengal health scheme annexure 2 form download FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to West Bengal Health Scheme Reimbursement Form For Pensioners

  • viii
  • vii
  • Smt
  • pursuance
  • claimant
  • sanctioning
  • Thallasaemia
  • CertificateCumStatement
  • essentiality
  • IV1
  • govt
  • Cerebrovascular
  • empanelled
  • III
  • IX
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.