Get West Bengal Health Scheme 2008 Form Iv3 Cum

This guide provides a comprehensive overview of how to complete the West Bengal Health Scheme 2008 FORM IV3 Cum online. By following these steps, you will be able to effectively fill out the essentiality certificate cum statement of expenditure for treatment services taken from a non-recognised private hospital or nursing home.

Follow the steps to accurately complete the form.

1. Press the 'Get Form' button to access the form and open it in the chosen editor.
2. In the first section, provide the name of the government pensioner or family pensioner along with their identification number.
3. Next, input the name of the office where the ex-government employee was sanctioned their pension.
4. Fill in the name of the patient, their relationship with the ex-government employee, and the patient's identification number.
5. Move to the details of expenditure section. Start by mentioning the diagnosed disease from the provided list.
6. Specify the name and address of the hospital where the treatment was received.
7. Indicate the period of treatment for which you are claiming expenses.
8. List the total number of original vouchers related to the treatment.
9. Detail the amount claimed in a separate annexure if needed. Include a brief description of items, the treatment period, amount claimed, and the amount admissible as per the approved package rate.
10. Calculate the total amount claimed and provide it in both figures and words.
11. Sign the form, write your name in block letters, and provide your address.
12. In the certification section, the treating specialist must affirm that the patient was admitted and outline the specific procedure or operation performed.
13. The treating specialist should also certify that relevant bills and vouchers have been verified and are accurate.
14. Lastly, ensure the signature of the treating specialist is accompanied by an official seal along with the countersignature from the medical superintendent or administrative officer of the hospital.
15. Once all information is filled in, save your changes, download the completed form, and print or share it as needed.

Complete your document online today for an efficient filing process.