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Get India Form MRC (S)

L CGHS Card Holder & : Designation : (b) CGHS Ben ID No. (c) Employee Code No. (d) Ward Entitlement -Pvt./Semi-Pvt./General Basic Pay (excluding Grade Pay) (e) Full Address : : : : : (f) Mobile telephone No. and e-mail address, if any: 2. (a) Patient's Name : (b) Patient's CGHS Ben ID No. : (c) Relationship with the Principal CGHS card holder : 3. Name & address of the hospital/ diagnostic centre / imaging centre where treatment is taken or tests done: 4. Whether the hospital/diagnostic im.

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