CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL 2004 FORM FOR REIMBURSEMENT OF
MEDICAL CLAIMS OF CGHS BENEFICIARIES
Computer No. …………………………………………
(To be filled by the Claimant)
1 CGHS Token No. and Place of Issue :
2 Validity of CGHS Token Card : From……………………………………….. to ……………………………………..
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) :
4 Full Address :
5 Telephone No. : (O) (R)
6 E-mail Adress, If any :
7 Name of the Bank ……………………………………. : Branch……………………………… SB A/C ……………………………………..
Branch MICR Code…………………………………… Tel. No. Bank Branch ……………………………………………………………
Name of the Patient & Relationship with
8 :
Card Holder
Status tick () (Govt. Servant/ Pensioner/ Serving employee of pensioner of autonomous body/ Member of
9 Parliament/ Ex-M.P./ Ex-Governor/ Former Judge of Supreme Court/ Former Judge of High Court/ Freedom
Fighter/ Legal Heir/ Others
10 Basic Pay/ Basic Pension :
11 Name of the Hospital with Address :
(a) OPD treatment and investigations :
(b) Indoor Treatment :
12 Date of Admission …………………………………… Date of Discharge…………………In case of Indoor Treatment only)
13 Total amount Claimed
(a) OPD Treatment :
(b) Indoor Treatment :
14 Detail of Referral :
15 Detail of Medical Advance, if any :
CENTRAL GOVERNMENT HEALTH SCHEME
MODIFIED CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS
1 CGHS Token No. and Place of Issue :
2 Validity of CGHS Token Card : From……………………………………….. to ……………………………………..
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) :
4 Status (Govt. servant/ Pensioner/ Others) :
The following documents are submitted
5
(Please Tick () the relevant Columns)
(a) Medical 2004 Form : Yes No
(b) Photocopy of CGHS Card : Yes No
(c) No. of Original Bills : Yes No
(d) Copy of Discharge Summary : Yes No
(e) Copy of Referral by Specialist/ CMO : Yes No
(f) Whether the hospital has given breakup
: Yes No
for lab investigation
(g) Original papers have been lost, the
following documents are submitted -
(i) Photocopies of Claim Papers : Yes No
(ii) Affidavit on Stamp Paper : Yes No
(h) Incase of death of card holder, the
following documents are submitted -
(i) Affidavit on Stamp Paper by Claimant : Yes No
(ii) No objection from other legal heirs
: Yes No
on Stamp Paper
(iii) Copy of Death Certificate : Yes No
Date :………………………………… Signature of CGHS Card Holder
Tel. No. (O) :
(R) :
e-mail ID :
Name of the Bank ………………………………………………………… Branch …………………………………… SB A/C No…………………………
Branch MICR Code ………………………………………………………. Tel. No. of Bank Branch ………………………………………………………
DECLARATION
I hereby declare that the 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 dependant on me. I am a CGHS beneficiary and
the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules.
Date Signature of CGHS Card Holder
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL 2004 FORM FOR REIMBURSEMENT OF
MEDICAL CLAIMS OF CGHS BENEFICIARIES
Computer No. …………………………………………
(To be filled by the Claimant)
1 CGHS Token No. and Place of Issue : 27491
2 Validity of CGHS Token Card : From……………………………………….. to ……………………………………..
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) : SUNIL KUMAR VERMA
4 Full Address : O/O the Pr. DIT (Inv.), Patna
3rd Floor, CR Building, B. C. Patel Path
Patna-1
5 Telephone No. : (O) 8986911082 (R)
6 E-mail Address, If any :
7 Name of the Bank SBI : Branch Alankar, Boring Road, Patna SB A/C 31886473478
Branch MICR Code…………………………………… Tel. No. Bank Branch ……………………………………………………………
8 Name of the Patient & Relationship with : Self
Card Holder
Status tick () (Govt. Servant/ Pensioner/ Serving employee of pensioner of autonomous body/ Member of
9
Parliament/ Ex-M.P./ Ex-Governor/ Former Judge of Supreme Court/ Former Judge of High Court/ Freedom
Fighter/ Legal Heir/ Others
10 Basic Pay/ Basic Pension : Rs.16750/- + Rs.4600/- = Rs.21350/-
11 Name of the Hospital with Address :
(c) OPD treatment and investigations :
(d) Indoor Treatment :
12 Date of Admission …………………………………… Date of Discharge…………………In case of Indoor Treatment only)
13 Total amount Claimed
(c) OPD Treatment : Rs.882/-
(d) Indoor Treatment :
14 Detail of Referral : CGHS
15 Detail of Medical Advance, if any :
CENTRAL GOVERNMENT HEALTH SCHEME
MODIFIED CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS
1 CGHS Token No. and Place of Issue : 27491
2 Validity of CGHS Token Card : From……………………………………….. to ……………………………………..
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) : SUNIL KUMAR VERMA
4 Status (Govt. servant/ Pensioner/ Others) : GOVERNMENT SERVANT
The following documents are submitted
5
(Please Tick () the relevant Columns)
(a) Medical 2004 Form : Yes No
(b) Photocopy of CGHS Card : Yes No
(c) No. of Original Bills : Yes No
(d) Copy of Discharge Summary : Yes No
(e) Copy of Referral by Specialist/ CMO : Yes No
(f) Whether the hospital has given breakup
: Yes No
for lab investigation
(g) Original papers have been lost, the
following documents are submitted -
(i) Photocopies of Claim Papers : Yes No
(ii) Affidavit on Stamp Paper : Yes No
(h) Incase of death of card holder, the
following documents are submitted -
(i) Affidavit on Stamp Paper by Claimant : Yes No
(ii) No objection from other legal heirs
: Yes No
on Stamp Paper
(iii) Copy of Death Certificate : Yes No
Date :………………………………… Signature of CGHS Card Holder
Tel. No. (O) :
(R) :
e-mail ID :
Name of the Bank State Bank of India Branch : Alankar Place, Boring Road, Patna SB A/C No : 31886473478
Branch MICR Code ………………………………………………………. Tel. No. of Bank Branch ………………………………………………………
DECLARATION
I hereby declare that the 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 dependant on me. I am a CGHS beneficiary and
the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules.
Date Signature of CGHS Card Holder
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL 2004 FORM FOR REIMBURSEMENT OF
MEDICAL CLAIMS OF CGHS BENEFICIARIES
Computer No. …………………………………………
(To be filled by the Claimant)
1 CGHS Token No. and Place of Issue : 2733270
2 Validity of CGHS Token Card : From……………………………………….. to ……………………………………..
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) : KUMAR ABHAY
4 Full Address : O/O the Pr. DIT (Inv.), Patna
3rd Floor, CR Building, Patna - 1
5 Telephone No. : (O) 8986911364 (R)
6 E-mail Adress, If any :
7 Name of the Bank SBI : Branch Danapur SB A/C 030103660355
Branch MICR Code…………………………………… Tel. No. Bank Branch ……………………………………………………………
8 Name of the Patient & Relationship with : Smt. Maya Devi
Card Holder Mother
Status tick () (Govt. Servant/ Pensioner/ Serving employee of pensioner of autonomous body/ Member of
9
Parliament/ Ex-M.P./ Ex-Governor/ Former Judge of Supreme Court/ Former Judge of High Court/ Freedom
Fighter/ Legal Heir/ Others
10 Basic Pay/ Basic Pension : Rs.11940/- + Rs.4200/- = Rs.16140/-
11 Name of the Hospital with Address :
(e) OPD treatment and investigations :
(f) Indoor Treatment :
12 Date of Admission …………………………………… Date of Discharge…………………In case of Indoor Treatment only)
13 Total amount Claimed
(e) OPD Treatment : Rs.20800/-
(f) Indoor Treatment :
14 Detail of Referral :
15 Detail of Medical Advance, if any :
CENTRAL GOVERNMENT HEALTH SCHEME
MODIFIED CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS
1 CGHS Token No. and Place of Issue : 2733270
2 Validity of CGHS Token Card : From……………………………………….. to ……………………………………..
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) : KUMAR ABHAY
4 Status (Govt. servant/ Pensioner/ Others) : GOVERNMENT SERVANT
The following documents are submitted
5
(Please Tick () the relevant Columns)
(i) Medical 2004 Form : Yes No
(j) Photocopy of CGHS Card : Yes No
(k) No. of Original Bills : Yes No
(l) Copy of Discharge Summary : Yes No
(m) Copy of Referral by Specialist/ CMO : Yes No
(n) Whether the hospital has given breakup
: Yes No
for lab investigation
(o) Original papers have been lost, the
following documents are submitted -
(i) Photocopies of Claim Papers : Yes No
(ii) Affidavit on Stamp Paper : Yes No
(p) Incase of death of card holder, the
following documents are submitted -
(i) Affidavit on Stamp Paper by Claimant : Yes No
(ii) No objection from other legal heirs
: Yes No
on Stamp Paper
(iii) Copy of Death Certificate : Yes No
Date :………………………………… Signature of CGHS Card Holder
Tel. No. (O) :
(R) :
e-mail ID :
Name of the Bank State Bank of India Branch : Danapur SB A/C No : 030103660355
Branch MICR Code ………………………………………………………. Tel. No. of Bank Branch ………………………………………………………
DECLARATION
I hereby declare that the 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 dependant on me. I am a CGHS beneficiary and
the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules.
Date Signature of CGHS Card Holder
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL 2004 FORM FOR REIMBURSEMENT OF
MEDICAL CLAIMS OF CGHS BENEFICIARIES
Computer No. …………………………………………
(To be filled by the Claimant)
1 CGHS Token No. and Place of Issue : 4449531
2 Validity of CGHS Token Card : From……………………………………….. to 31.05.2030
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) : RAJESH KUMAR JHA
4 Full Address : O/O the Pr. DIT (Inv.), Patna
3rd Floor, CR Building, Patna - 1
5 Telephone No. : (O) 8986912227 (R)
6 E-mail Address, If any :
7 Name of the Bank SBI : Branch Niyojan Bhawan SB A/C No. : 32136861130
Branch MICR Code…………………………………… Tel. No. Bank Branch ……………………………………………………………
8 Name of the Patient & Relationship with : Rajesh Kumar Jha
Card Holder Self
Status tick () (Govt. Servant/ Pensioner/ Serving employee of pensioner of autonomous body/ Member of
9
Parliament/ Ex-M.P./ Ex-Governor/ Former Judge of Supreme Court/ Former Judge of High Court/ Freedom
Fighter/ Legal Heir/ Others
10 Basic Pay : Rs. 56900/-
11 Name of the Hospital with Address :
(a) OPD treatment and investigations :
(b) Indoor Treatment :
12 Date of Admission …………………………………… Date of Discharge…………………In case of Indoor Treatment only)
13 Total amount Claimed
(g) OPD Treatment : Rs.1989/-
(h) Indoor Treatment :
14 Detail of Referral :
15 Detail of Medical Advance, if any :
CENTRAL GOVERNMENT HEALTH SCHEME
MODIFIED CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS
1 CGHS Token No. and Place of Issue : 4449531
2 Validity of CGHS Token Card : From……………………………………….. to 31.05.2030
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) : RAJESH KUMAR JHA
4 Status (Govt. servant/ Pensioner/ Others) : GOVERNMENT SERVANT
The following documents are submitted
5
(Please Tick () the relevant Columns)
(q) Medical 2004 Form : Yes No
(r) Photocopy of CGHS Card : Yes No
(s) No. of Original Bills : Yes No
(t) Copy of Discharge Summary : Yes No
(u) Copy of Referral by Specialist/ CMO : Yes No
(v) Whether the hospital has given breakup
: Yes No
for lab investigation
(w) Original papers have been lost, the
following documents are submitted -
(i) Photocopies of Claim Papers : Yes No
(ii) Affidavit on Stamp Paper : Yes No
(x) In case of death of card holder, the
following documents are submitted -
(i) Affidavit on Stamp Paper by Claimant : Yes No
(ii) No objection from other legal heirs
: Yes No
on Stamp Paper
(iii) Copy of Death Certificate : Yes No
Date :………………………………… Signature of CGHS Card Holder
Tel. No. (O) :
(R) :
e-mail ID :
Name of the Bank State Bank of India Branch : Niyojan Bhawan SB A/C No : 32136861130
Branch MICR Code ………………………………………………………. Tel. No. of Bank Branch ………………………………………………………
DECLARATION
I hereby declare that the 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 CGHS beneficiary and
the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules.
Date Signature of CGHS Card Holder
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL 2004 FORM FOR REIMBURSEMENT OF
MEDICAL CLAIMS OF CGHS BENEFICIARIES
Computer No. …………………………………………
(To be filled by the Claimant)
1 CGHS Token No. and Place of Issue : 4449531
2 Validity of CGHS Token Card : From……………………………………….. to 31.05.2030
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) : RAJESH KUMAR JHA
4 Full Address : O/O the Pr. DIT (Inv.), Patna
3rd Floor, CR Building, Patna - 1
5 Telephone No. : (O) 8986912227 (R)
6 E-mail Address, If any :
7 Name of the Bank SBI : Branch Niyojan Bhawan SB A/C No. : 32136861130
Branch MICR Code…………………………………… Tel. No. Bank Branch ……………………………………………………………
8 Name of the Patient & Relationship with : Rajesh Kumar Jha
Card Holder Self
Status tick () (Govt. Servant/ Pensioner/ Serving employee of pensioner of autonomous body/ Member of
9
Parliament/ Ex-M.P./ Ex-Governor/ Former Judge of Supreme Court/ Former Judge of High Court/ Freedom
Fighter/ Legal Heir/ Others
10 Basic Pay : Rs. 56900/-
11 Name of the Hospital with Address :
(i) OPD treatment and investigations : PARAS HMRI Hospital, Patna
(ii) Indoor Treatment :
12 Date of Admission …………………………………… Date of Discharge……………… (In case of Indoor Treatment only)
13 Total amount Claimed
(a) OPD Treatment/Tests : Rs. 408/-
(b) Indoor Treatment :
14 Detail of Referral :
15 Detail of Medical Advance, if any : NIL
CENTRAL GOVERNMENT HEALTH SCHEME
MODIFIED CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS
1 CGHS Token No. and Place of Issue : 4449531
2 Validity of CGHS Token Card : From……………………………………….. to 31.05.2030
& Entitlement : Pvt./Semi Pvt./General
3 Full name of the Card Holder (Block Letter) : RAJESH KUMAR JHA
4 Status (Govt. servant/ Pensioner/ Others) : GOVERNMENT SERVANT
The following documents are submitted
5
(Please Tick () the relevant Columns)
(a) Medical 2004 Form : Yes No
(b) Photocopy of CGHS Card : Yes No
(c) No. of Original Bills : Yes No
(d) Copy of Discharge Summary : Yes No
(e) Copy of Referral by Specialist/ CMO : Yes No
(f) Whether the hospital has given breakup
: Yes No
for lab investigation
(g) Original papers have been lost, the
following documents are submitted -
(i) Photocopies of Claim Papers : Yes No
(ii) Affidavit on Stamp Paper : Yes No
(h) In case of death of card holder, the
following documents are submitted -
(i) Affidavit on Stamp Paper by Claimant : Yes No
(ii) No objection from other legal heirs
: Yes No
on Stamp Paper
(iii) Copy of Death Certificate : Yes No
Date : 19.09.2018 Signature of CGHS Card Holder
Tel. No. (O) :
(R) :
e-mail ID :
Name of the Bank State Bank of India Branch : Niyojan Bhawan SB A/C No : 32136861130
Branch MICR Code ………………………………………………………. Tel. No. of Bank Branch ………………………………………………………
DECLARATION
I hereby declare that the 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 CGHS beneficiary and
the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules.
Date : 19.09.2018 Signature of CGHS Card Holder
