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Get West Bengal Health Scheme Form D1 Download Pdf

Name of the Govt. employee with identification : No. 2. Name of Office of the Govt. employee with : address 3. Name of the patient, relationship with Govt. : Employee & Identification No. 4. Details of expenditure : : (I) (II) Name & Code No. of the empanelled / : Govt. recognized Hospital (III) Period of OPD treatment (IV) Total No. of original vouchers & money : receipts (V) Sl. No. Name of the diagnosed disease (*vide list enclosed) Amount claimed for OPD treatment Descr.

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