Forms

Government of West BengalFinance Department Audit Branch Medical Cell No. 6953-F (MED) Memorandum In the process of implementation of the West Bengal Health Scheme, 2008 the Government from some time past was considering for amendment of Forms regarding enrolment under the Health Scheme and settlement of claims. Accordingly, the Governor is pleased to publish the following amended Forms under the West Bengal Health Scheme, 2008 and guidelines for settlement of claims. 2. Under Clause-7 (1) of the West Bengal Health Scheme, 2008, costs of OPD treatment of ten listed diseases are reimbursable. Reimbursement of the cost of medical treatment of such diseases may be allowed when the attending physician of recognized hospital clearly certifies that the beneficiary was/ has been suffering from any of the listed diseases of Clause-7(1) of the Health Scheme. Essentiality Certificate for treatment under Clause-7 (1) of the Health Scheme should be furnished in Form-‘D1’/ Form-‘IV1’. Cases relating to Clause-6, Clause-7 (2) or Clause-9 of the Health Scheme may be settled following provisions of those Clauses. Essentiality Certificates for those cases should be furnished in Form-‘D2’/ Form-‘IV2’. 3. Revised terms and conditions for rendering services under the Health Scheme and revised rate list have been published under the notification no. 796-F (MED), dated 31-012011. Guidelines for settlement of claims along with list of inadmissible items have also been published under the memo nos. 797-F (MED), dated 31-01-2011 and 6586-F (MED), dated 29-06-2011 respectively. Accordingly, all claims should be settled strictly following the provisions of the Health Scheme, guidelines and rate list. 4. For enrolment and settlement of claims under the Health Scheme, henceforth, revised Forms shall be used (attached herewith). 5. Health Scheme with amendments, revised rate list, list of empanelled and recognized Health Care Organisations, Forms, Guidelines and related Government Orders, Memorandum of Agreement with the Health Care Organisations may be available in the official website of the Finance Department www.wbfin.nic.in – West Bengal Health Scheme, 2008. Sd/- S.K. Chattopadhyay Officer on Special Duty and Ex-officio Special Secretary to the Government of West Bengal Dt. 11-07-2011 West Bengal Health Scheme, 2008 FORM A Application for enrolment under the West Bengal Health Scheme, 2008. (See sub-clause (1) of clause (4) TO: The ___________________________ (Cadre Controlling Authority/ Head of Office) Sir, I Shri/ Smt ___________________ (Designation) ____________________________ attached to _____________________ (office) under __________________________ (Department) do hereby opt for coming under the West Bengal Health Scheme, 2008 with effect from 1st day of ____________, _________. (Month) (Year) The particulars of the members of my family as defined in para 3(e) of the Scheme as amended under notification no. 6722-F dt. 09.07.09 are as follows: Name of Government Employee Designation Residential Address : : : Date of birth Date of entry into Government Service Date of superannuation Present pay (Band pay + Grade pay) G.P.F. A/C No. Details of Family Sl. NO: Name 1. 2. 3. 4. 5. ____________________ ____________________ ____________________ ____________________ ____________________ : : : : : Date of Birth/ Relationship Monthly income, Age if any ___________ __________ ______________ ___________ __________ ___________ __________ ___________ __________ ___________ __________ ______________ ______________ ______________ ______________ I do hereby declare that upon enrolment under the above scheme I shall forgo the regular monthly medical allowance drawn by me as a part of salary. I further declare that I shall abide by the provisions of the West Bengal Health Scheme, 2008, as may be in force from time to time. _____________________ Signature of the Applicant West Bengal Health Scheme, 2008 FORM B Certificate for enrolment under the West Bengal Health Scheme, 2008 (See sub-clause (3) of clause 4) Certified that Shri/Smt. ___________________________ (designation) _________ _____________ _______________________ attached to _______________________ ____Department has been enrolled under the West Bengal Health Scheme, 2008, with effect from 1st day of _____________, _________. (Month) (Year) The particulars of the Govt. employee and dependent members of family as defined in para 3(e) of the Scheme and amended under notification no. 6722-F dt. 09.07.09 are as follows: Name of Government employee Designation Residential address : : : Date of birth Date of entry into Government service Date of superannuation Present pay (Band Pay + Grade Pay) G.P.F. Account No. Details of Family Sl. No. Name 1. 2. 3. 4. 5. : : : : : Date of birth/Age Relationship Monthly income, if any Signature of the Cadre Controlling Authority/ Head of the Office Treasury Buildings. He is requested to discontinue the drawal of regular monthly medical allowance in respect of Shri/ Smt.Accountant General (A&E). __________ Dt. No. _____________ Copy forwarded for information and necessary action to: 1. ________.The _____________________________________ (Drawing and Disbursing Officer). 4. Signature of the Cadre Controlling Authority/ Head of the Office . Writers’ Buildings. (Year).Medical Cell. 3. Kolkata. 2008 Memo.1.West Bengal Health Scheme.Shri/ Smt _______________________________________________ (designation) 2. Finance (Audit) Department. Kolkata. ______________________________with effect from 1st day of __________ (Month). Date of superannuation 6. (a) OPD treatment : : : Private/ Semi-Private/ General Ward : Self or beneficiary : : (b) Indoor treatment/ Day Care : 11. Medical treatment done 9. Period of OPD treatment 12. Name of the beneficiary & relationship with the Government employee 10. 2008 FORM C Application Form for settlement of claim for reimbursement under the West Bengal Health Scheme. Identification No. employee with designation (in Block letters) 3. Full name of the Govt. : 5. employee : 2. Full Address: (i) Office : : (ii)Residence : 4. 2008 (See sub-clause (1) of clause 12) (To be filled in by the applicant) 1.West Bengal Health Scheme. Enrolled under the Health Scheme w.e. Disease : : : . Period of indoor treatment 13. of the Govt. Pay (Band Pay + Grade Pay) 7. Name of the Hospital with address and code no.f. Accommodation Category [put (√) mark)] 8. if any (a) Amount (b) Order no.West Bengal Health Scheme. 797-F (MED). digital hearing aid. 16. dt. and date (c) Sanctioning Authority : : : 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. as per Memo No. 2008 14. I agree for the reimbursement as is admissible under the rules. Details of Medical advance. Total amount claimed(a) OPD treatment (b) Indoor treatment Total : : : 15. Details of permission (a) For treatment in speciality hospital : outside the State (b) For human organ transplantation/ : ICD/ CRT/ Dual Chamber Pacemaker/ more than two stents/ more than one drug eluting stents. Signature of the Govt. 31-01-11. etc. 2008. Employee Date: . and the enrolment under the Scheme was valid at the time of treatment. I am a beneficiary of the West Bengal Health Scheme. ) Radiological investigations (attach separate list. 2. Name of the Govt. if required. employee with identification No. of original vouchers & money receipts (V) Amount claimed for OPD treatment : : : Amount admissible (for official use) Sl. of consultations) Pathological investigations (give Break-up in a separate annexure with code no. No. if required) Special devices like hearing aid/artificial appliances etc.) Medicines (give details of purchase in separate annexure.West Bengal Health Scheme. with code no. employee with address : : 3. : 4. Details of expenditure: (I) Name of the diagnosed disease * ( vide list enclosed) : (II) Name & Code No. Name of Office of the Govt. recognized Hospital : (III) Period of OPD treatment (IV) Total No. (a) Description of items Consultation fees (indicate total no. Name of the patient. Employee & identification No. 2008 FORM “D1” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for OPD Treatment [See sub-clause 12 (3) & clause 7(1)] 1. (specify) Amount Claimed (b) (c) (d) (e) . of the empanelled/ Govt. relationship with Govt. Certified that the patient. (xi) None of the above list (Specify name of the ailment) [vide Para-10 of Memo No. 2008 (i) Malignant diseases. Certified that the relevant bills/vouchers have been verified by me in pursuance of the latest approved rates of the WBHS. (vii) Malignant malaria.West Bengal Health Scheme. 797-F (MED). (iii) Hepatitis B/C and other liver diseases. (viii) Renal failure. Counter signed by (Signature of the Treating Specialist with official seal) Administrative officer/Medical Superintendent of the empanelled/ recognized Hospital with official seal * OPD Disease List as per clause –7 of the WBHS.__________________ of the WBHS OPD list below*. 2008 (f) Miscellaneous (specify) Total (Rupees: only) (Signature of Claimant) Name in Block Letters Address: 1. 2.__________________________ was/ has been suffering from___________________as listed in Sl. (v) Heart diseases. (vi) Neurological disorders/Cerebrovascular disorders. (x) Injuries caused by accidents. (iv) Insulin-dependent diabetes. dated 31-01-2011] . No. (ix) Thallasaemia/Bleeding disorders/Platelet disorders. (ii) Tuberculosis. Sri/Smt. 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. Name of the patient. clause 6. Name of Office of the Govt. (1) (i) (ii) (iii) (iv) (v) Procedure Name (2) Procedure Code No. (3) Amount Claimed (Rupees) (4) Amount admissible (Rupees) (for official use) (5) Miscellaneous (Specify & give details in separate sheet. 2. of original vouchers & money receipts (V) Details of Amount claimed (A) for Package treatment from ______ to ______ : : : : : Sl No. Employee & identification No. : 4. clause 7(2) & clause 9] 1. Details of expenditure: (I) Name of the diagnosed disease (II) Name & Code No. relationship with Govt. 2008 FORM “D2” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for Indoor/Day Care Treatment and related OPD treatment [See Clause 12(3). employee with address : : 3. employee with identification No.West Bengal Health Scheme. Name of the Govt. if necessary) Total=Rupees . of the empanelled/ Government recognized Hospital (III)Period of Indoor/Day Care treatment (IV)Total No. in separate annexure) Pathological investigations Radiological investigations (c) Medicines . 2008 (B) for Non-Package treatment from ______ to _______ Amount Claimed (Rupees) (4) Amount admissible (Rupees) (for official use) (5) Sl No. in separate annexure) (a) Indoor visit of specialist/ super specialist (b) Radiological Investigations (c) Pathological Investigations (d) Medicines (e) Artificial devices (f) Miscellaneous (specify) Total : (VI) Related OPD treatment in terms of Clause-9 or Clause-7(2) Amount Claimed (Rupees) (3) Amount admissible (Rupees) (for official use) (4) =Rupees ___________ ___________ ____________ ____________ Sl No. (1) (i) Description of items (2) Room Rent : (a) Ward (b) ICU/ ITU/ CCU/ NICU/ PICU (c) HDU/Step Down Unit/Burn Unit Item Code (3) (ii) Charges for : (give details with code nos. of consultations) Charges for : (give details with code nos. _____ (1) (i) (ii) (a) (b) Description of items (2) Consultation fees (indicate total no.West Bengal Health Scheme. 3. Certified that the relevant bills/vouchers have been verified by me as per latest approved rates of the WBHS. (Signature of the Treating Specialist with official seal) Countersigned by Medical Superintendent/ Administrative officer of the empanelled/ recognized Hospital with seal . Certified that the services of Special Nurse/Ayah were required from ________________ to ______________ that were absolutely essential for the recovery of the patient. 2008 and the expenditures shown above are correct and the treatment services provided were essential and minimum that required for the recovery of the patient. (specify) Miscellaneous (specify) = Rupees =Rupees only) (3) (4) ___________ ____________ ______________ ______________ (Signature of Claimant) Name in Block Letters Address: 1. 2. Specific procedure/Operation performed was ___________________________ on _______________. 4. Conservative treatment provided from __________________ to __________________. 2008 (1) (d) (e) Total: Grand Total (package + non-package+ OPD amount) (Rupees: (in words) (2) Special devices like hearing aid/artificial appliances etc.West Bengal Health Scheme. if required) Amount Admissible (60% of approved Package rate) (Rupees) (for official use) (5) Sl. dt.2011] 1. Employee & identification No. 31. of original vouchers : : Details of Amount claimed: (give details in separate annexure. No.01. Details of expenditure: (I) Name of disease (* vide list enclosed) Name & Address of the Hospital : (II) : (III) Period of treatment (IV) Total No. 797-F (MED).West Bengal Health Scheme. employee with address : : 3 Name of the patient. _______ (1) (i) (ii) (iii) Description of items (* vide list enclosed) (2) Treatment Period (3) Amount claimed (Rupees) (4) . relationship with Govt. Name of Office of the Govt. 2 Name of the Govt. employee with identification No. 2008 FORM “D3” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for treatment services taken from WB Health Scheme non-recognised Private Hospital/ Nursing Home [See Para-23 of the FD memo no. : 4. (b) Acute Appendicitis operation on emergency basis. 2. Certified that the treatment was done in an organization that has a License under the West Bengal Clinical Establishment Act and Rules and the licence no is __________________________ and is valid up to ____________. 31-01-2011 (a) Accidental injury. (c) Delivery on emergency basis. Certified that the patient had been admitted under my care at _________________Hospital/Nursing Home as an emergency case.West Bengal Health Scheme. (e) Removal of foreign body on emergency basis. 3. dt. The Specific procedure/Operation performed was _____________________________ on _______________. Countersigned by Medical Superintendent/ Administrative officer of the Private Hospital/ Nursing Home with seal (Signature of the Treating Specialist with official seal) *List as per Para 23 of Memo No. (d) Haemodialysis. 2008 (iv) Total= Rupees ____________ _________________ (Rupees: (in words) only) (Signature of Claimant) Name in Block Letters Address: 1. Certified that the relevant bills/vouchers have been verified by me and the expenditure shown is correct and the treatment services provided were essential and minimum that was required for the recovery/stabilization of the patient. 797-F (MED). . West Bengal Health Scheme. Disease : Private/Semi-Private/General ward : 7. Name of the hospital where treatment was done/to be done /is going on : 8. and address : 9. 2008 FORM E Checklist for Reimbursement of Medical Claims/ Sanction of Advance (See sub-clause (3) of clause 12) 1. Notification No. & date of enrolment 2. : Yes/No. a)Treatment done within the State- : from _________ to_________ : from _________ to_________ : : : (i) Copy of intimation letter furnished : (Vide Clause-11 of the West Bengal Health Scheme. Details of advance sanctioned a) Amount b) Order No. etc. Entitlement of accommodation (Put tick mark) 6. Full name & designation (block letters) 3. Employee’s Identification No. : c) Validity of the Card up to : 5. mention – : : : : : : a) Name of the beneficiary and relationship with employee : b) Beneficiary’s Identification No. (a) Name of office with address (b) Directorate (c) Department 4. Whether treatment was done in non-empanelled hospital : Yes/No If yes – a) Name of the hospital/nursing home with Clinical Establishment licence No. if for his beneficiary. Period of treatment: a) OPD b) Indoor/ Day Care treatment 10. 2008) (ii)Copy of permission letter furnished : (For human organ implantation/ Dual-chamber pacemaker/ AICD/ CRT/ more than one drug eluting stents Implantation.) (Vide Para-8 & 9 of Finance Deptt. . dated 31-01-2011) b) Treatment done outside the State – Copy of permission letter furnished Yes/No. Whether claim is for employee himself or his beneficiary. & date c) Sanctioning Authority 11. Yes/No. 796-F (MED). ... employee II) Beneficiary (b) Essentiality Certificate (as specified) (c) Copy of discharge summary (d) Copy of OPD prescription (e) Total Number of original bills & cash memos (f) Detailed list/Statement of medicines furnished (g) Detailed list of investigations furnished : : : : : : : : : : : : : Yes/No....West Bengal Health Scheme. (for continuous OPD treatment) (B) If not. 2008 12. Yes/No Yes/No Yes/No (h) Original papers have been lost the following documents are submitted(I) Photocopies of claim papers (II) Affidavit on stamp paper (III)Photo copy of Police Diary : : : Yes/No.. (III) Copy of death certificate : Yes/No... whether delay in preferring claim has been condoned by the West Bengal Health Scheme Authority under the Finance Department 13... Yes/No... Yes/No Yes/No. Yes/No. (II) No objection from other legal heirs on stamp papers : Yes/No..... (A) Whether the claim for reimbursement has been preferred within (i) three months from the date of discharge of indoor treatment (ii) three months from the date of consultation of OPD treatment (iii) three months from the date of purchase of medicines.......... Signature of the Applicant .. Dated.. The following documents are submitted (please tick [√] the relevant column) (a) Photocopy of the Health Scheme Identity Card of I) Govt. employee following documents are submitted(I) Affidavit on stamp paper by claimant : Yes/No. (i) In case of death of Govt. Yes/No. etc... Name of the Government employee 2. No. 4. No.* Signature of Cadre controlling authority /Head of the office. . recognised under the West Bengal Health Scheme. If any. Employee Identification No. * Strike out whichever is not applicable.F. 5. 2.West Bengal Health Scheme. Designation 4. Photograph (Stamp size) Shri/Smt. Date of birth 7. 2008 in the entitled class mentioned in Sl.) 3. Residential address : : : : : : : : 9. 5. Present Pay (Band pay+ Grade Pay) 5. 3. No. Age Relationship : Monthly Income. This permit is valid for 6 (six) months from the date of enrolment. Name 1. Date of Superannuation 8. 2008 with effect from __________________ He/She and his/her family members are entitled to the medical attendance and treatment in a Government Hospital/empanelled Private Hospital or Institution etc. Details of Family Sl.P. 2008 FORM-F Temporary Family Permit [See sub-clause (9) of clause 10] 1. (GPF No. ______________________________________attached to _____________ _______________________________________________________________ (office) under _________________________________________________________ Department has been enrolled under the West Bengal Health Scheme. Entitlement of accommodation 6.* The temporary family permit is valid till the New entrant Government employee gets G. 2008 (Government pensioner/ family pensioner) [See sub-para (iv) of para-4 of memo no. if any I do hereby declare that upon enrolment under the above scheme I shall forgo the regular medical relief drawn by me as part of pensionary benefits. under the Health Scheme : during service period before retirement/ death 12. 2008 as may be in force from time to time. 2.09. 4. : : : 8.West Bengal Health Scheme. 2008 FORM I Application for enrolment under the West Bengal Health Scheme. No. Pension Payment Order No. 12 may please be enrolled under the West Bengal Health Scheme. employee at Sl. I further declare that I shall abide by the provisions of the West Bengal Health Scheme. No. Last Pay (Band Pay+ Grade Pay) drawn before retirement/ death 6.e.(month)……………. 1. Date of Retirement/Death : 4.05. 2008 with effect from 1st day of ……………. 11. (* Strike out whichever is not applicable) My particulars are given below 1.] To The……………………………… (Pension Sanctioning Authority/ Competent Authority) Dear Sir. Employee 2. along with my dependent family members whose particulars are given below at Sl. / I ____________________________ family pensioner along with dependent family members of my late husband/ wife. 3475 F dt. and address : (In case of Pensioners residing in Kolkata) 10. No. 5. Basic Pension(before commutation) 7. 2008 w.(month)…………(year). Name of Treasury with address : (In case of Pensioners residing in the districts) 9. 12 may be enrolled under the West Bengal Health Scheme.f. Signature of the Applicant . I. Whether a beneficiary of the Health Scheme during service period : 11. Details of Family Sl. Ex-Govt. Residential Address : : 3. Name : Date of birth/Age Relationship Monthly income. Name of the Ex-Govt. Identification no. Name of Bank with account no.(year). 1st day of ……………. Department/ Office where rendered services : 5. 3. 20. 11.07. 2008. Name of the Ex-Govt. ________ (Year) (* Strike out whichever is not applicable) The particulars of the Ex-Govt.05. family pensioner has been enrolled under the West Bengal Health Scheme. with effect from 1st day of ____________ (Month).09.05. 2008. Residential Address : : 3.West Bengal Health Scheme. ________ (Year)/ Certified that Shri/ Smt _______________________. Department/ Office where rendered : services 5. Ex __________________________________________________ who was attached to _________________________________________________________ (office) under _____________________________ Department has been enrolled under the West Bengal Health Scheme.11. Employee 2. employee and members of family as defined in para 3(v) of memo no. 3475-F dt.09 are as follows:1. Last Pay (Band Pay+ Grade Pay) drawn before retirement/ death 6. Basic Pension (before commutation) : 7. with effect from 1st day of ____________ (Month). 7071-F.09 read with memo no. Pension Payment Order No. Name of Treasury and Bank with address from where pension is drawn (In case of Pensioners residing in the districts) : : : : . 8. 3475 F dt. 2008 FORM II Certificate of enrolment (Government pensioner/ family pensioner) [See sub-para (v) of para-4 of memo no. Date of Retirement/ Death 4. dt.] Certified that Shri/ Smt ________________________________________ . Identification no. The Treasury Officer ___________________________________ Treasury ________________________________________________________ (address). Name of Bank with account no. ___________________ ______________________________________________ / family pensioner) 2. Name : Date of birth/Age Relationship Monthly income. under the Health Scheme during service period before retirement/ death 11. 5. Shri/ Smt _________________________________ (Ex. West Bengal. Kolkata. The Accountant General (A & E). if any : Signature of the Pension Sanctioning Authority/ Competent Authority Copy forwarded for information and necessary action to: 1. Kolkata700001. 4. Details of Family Sl. 3.1. and address : (In case of Pensioners residing in Kolkata) 10. Writers’ Buildings. ______________________________________ Bank _____________________________________________________ (address). Signature of the Pension Sanctioning Authority/ Competent Authority . Finance (Audit) Department. 4. 2. The Branch Manager.West Bengal Health Scheme. Treasury Buildings. No. He is requested to discontinue the drawal of regular medical relief in respect of Shri/ Smt ____________________________ with effect from 1st day of _____________ (Month). ________ (Year). Medical Cell. 2008 9. 1. 5. 3. (i) OPD treatment : : : Private/Semi-Private/General Ward : Self or beneficiary (ii) Indoor treatment/ Day Care : 10.09. employee 8. 2. Period of O. : 5. Last Pay Drawn (Band Pay + Grade Pay)/ Basic Pension : 6.P. Enrolment under the Health Scheme w.05. (See sub-para (i) of para 11 of memo no.) (To be filled in by the applicant) 1. 2008 FORM III Application Form for settlement of claim for reimbursement. Full Address: (i) Office (from where retired)/ Pension Sanctioning Authority : : : (ii) Present Residence : 4.D. Disease : : : . 11. 3475 F dt. Pensioner / Family Pensioner (in Block letters) 3. Period of indoor treatment 12. Name of the Hospital with address & code no.West Bengal Health Scheme. Medical treatment done 7.f.e. Name of the beneficiary & relationship with the Ex-Govt. treatment 11. Accommodation Category (Put tick mark) 9. Identification No. Full name of Govt. Details of Medical advance. 2008 13. if any (only for treatment in Govt. 15. : : : : : : : 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. Details of permission (i) For treatment in Speciality Hospital outside the : State (ii) For human organ transplantation/ ICD/ CRT/ Dual Chamber Pacemaker/ more than two drug eluting stents. Total amount claimed – (i) OPD treatment (ii) Indoor treatment 14. etc. and card issued under the scheme was valid at the time of treatment. 2008. Hospital) (i) Amount sanctioned (ii) Order no. I agree for the reimbursement as is admissible under the rules. and date (iii) Sanctioning Authority (iv) D.O.D. Pensioner / Family Pensioner .West Bengal Health Scheme. I am a beneficiary of the West Bengal Health Scheme. Date: Signature of Govt. (a) (b) Description of items Consultation fees (indicate total no. employee & identification No. : 4. with code no. Name of the Govt. No. if required. of the empanelled/ recognised Hospital : (III) Period of OPD treatment : (IV) Total No.West Bengal Health Scheme.) Radiological investigations (attach separate list. if required) Amount Claimed Amount admissible (for official use) (c) (d) . employee/ Govt. pensioner/ family pensioner with identification No. 11. Name & address of Office of the Ex-Govt. relationship with Ex-Govt. of original bills & vouchers (V) Amount claimed for OPD treatment : : Sl.) Medicines (give details of purchase in separate annexure.05. Details of expenditure: (I) Name of the diagnosed disease ( vide list enclosed) * : (II) Name & Code No. of consultations) Pathological Investigations (give Break-up in a separate annexure with code no. Pensioner/ Pension Sanctioning Authority : 3. 3475 F dt. : 2.09. Name of the patient. 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. and clause-7 (1) of the Health Scheme] 1. 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. No. dated 31-01-2011] . (xi)None of the above list (Specify name of the ailment) [vide Para-10 of Memo No. (x) Injuries caused by accidents. 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.West Bengal Health Scheme. (iii) Hepatitis B/C and other liver diseases. 797-F (MED). (specify) (f) Miscellaneous (specify) Total (Rupees: only) (Signature of Claimant) Name in Block Letters Address: 1. (vi) Neurological disorders/Cerebrovascular disorders. (v) Heart diseases.__________________ of the WBHS OPD list below*. (ix) Thallasaemia/Bleeding disorders/Platelet disorders. (vii) Malignant malaria. (ii) Tuberculosis. Certified that the relevant bills/vouchers have been verified by me in pursuance of the latest approved rates of the WBHS. 2008 (i) Malignant diseases. Sri/Smt. (iv) Insulin-dependent diabetes.__________________________ was/ has been suffering from___________________as listed in Sl. 2008 (e) Special devices like hearing aid/artificial appliances etc. Certified that the patient. 2. (viii) Renal failure. if necessary) Total=Rupees . Employee & identification No.West Bengal Health Scheme. Code No. Name of the patient. Name of the Govt.11.3475-F Dt. Details of expenditure: (I) Name of the diagnosed disease (II) Name. 2008 FORM “IV2” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for Indoor/Day Care Treatment and related OPD treatment [See Para-5 of Memo.5. (3) Amount Claimed (Rupees) (4) (iii) (iv) (v) Miscellaneous (Specify & give details in separate sheet. : 3. (1) (i) (ii) Procedure Name (2) Procedure Code No. Clause6. of original bills & vouchers : : (V) Details of Amount claimed (A) for Package treatment from ________ to ________: Amount admissible (Rupees) (for official use) (5) Sl No.09. Name & address of Office of the Ex-Govt. Clause-7 (2)] 1. & Class of the empanelled/ recognised Hospital : : (III) Period of Indoor/Day Care treatment (IV) Total No. No. : 4. Pensioner/family pensioner with identification No. relationship with Ex-Govt. Employee/ Pension Sanctioning Authority : 2. (1) (i) Description of items (2) Room Rent : (a) Ward (b)ICU/ITU/CCU/NICU/PICU (c) HDU/ Step Down Unit/ Burn Unit Charges for : (give details with code nos. 2008 (B) for Non-Package treatment from __________ to ___________ Amount claimed (Rupees) (4) Amount Admissible (Rupees) (for official use) (5) Sl. No. in separate annexure) (a) Indoor visit of specialist/ super specialist Item Code (3) (ii) (b) Radiological Investigations (c) Pathological Investigations (d) Medicines (e) Artificial devices (f) Miscellaneous (specify) Total : =Rupees (VI) Related OPD treatment in terms of Clause-9 or Clause-7(2) Amount Claimed (3) Amount admissible (for official use) (4) Sl. (1) (i) (ii) Description of Items (2) Consultation fees (indicate total no.West Bengal Health Scheme. of consultations) Charges for: (give details with code nos. No. in separate annexure) (a) Pathological investigations . .. 3.. 2008 and the expenditures shown above are correct and the treatment services provided were essential and minimum that required for the recovery of the patient.. Certified that the services of Special Nurse/Ayah were required from ________________ to ______________ that were absolutely essential for the recovery of the patient..West Bengal Health Scheme. ...... Specific procedure/Operation performed was ___________________________ on _________________ 4... Grand Total (package + non-package+ OPD amount) (Rupees: (in words) =Rupees only) (Signature of Claimant) Name in Block Letters Address: 1... 2008 (1) (b) (2) Radiological investigations (3) (4) (c) (d) Medicines Special devices like hearing aid/artificial appliances etc.... Certified that the relevant bills/vouchers have been verified by me as per latest approved rates of the WBHS... 2.......………….... (Signature of the Treating Specialist with official seal) Countersigned by Medical Superintendent/ Administrative officer of the recognized Hospital with seal ......... Conservative treatment of ___________________________________ (Disease) done from ______________ to ________________. (specify) Miscellaneous (specify) (e) Total: =Rupees . of original vouchers Details of Amount claimed: (give details in separate annexure. 31. relationship with Ex-Govt. Details of expenditure: (I) Name of the disease (* vide list enclosed) Name & Address of the Hospital : 4. pensioner/family pensioner with identification No. Name of the patient. No.2011] 1. Name of the Govt. dt. 2008 FORM “IV3 ” Essentiality Certificate-cum-Statement of Expenditure Certified by Treating Specialist for treatment services taken from WB Health Scheme non-recognised Private Hospital/ Nursing Home [See Para-23 of the FD memo no. _______ (1) (i) (ii) (iv) (v) Description of items (* vide list enclosed) (2) Treatment Period (3) Amount claimed (Rupees) (4) Amount Admissible (60% of approved Package rate) (Rupees) (for official use) (5) Total= Rupees (Rupees : (in words) ______________ ________________ only) (Signature of Claimant) Name in Block Letters Address: . Name & address of Office of the Ex-Govt. employee/ Pension Sanctioning Authority : 2. : (II) : (III) Period of treatment (IV) Total No.01. Employee & identification No.West Bengal Health Scheme. : 3. if required) : : Sl. 797-F (MED). 797-F (MED). Certified that the relevant bills/vouchers have been verified by me and the expenditure shown is correct and the treatment services provided were essential and minimum that was required for the recovery/stabilization of the patient. Certified that the patient had been admitted under my care at _________________Hospital/Nursing Home as an emergency case. 2008 1. (e) Removal of foreign body on emergency basis. Certified that the treatment was done in an organization that has a License under the West Bengal Clinical Establishment Act and Rules and the licence no. (d) Haemodialysis. (b) Acute Appendicitis operation on emergency basis. (c) Delivery on emergency basis. 31-01-2011 (a) Accidental injury.West Bengal Health Scheme. . The Specific procedure/Operation performed was ___________________________________________ on __________________ 2. is____________________ and is valid up to ____________. dt. 3. Countersigned by Medical Superintendent/ Administrative officer of the Private Hospital/ Nursing Home with seal (Signature of the Treating Specialist with official seal) *List as per Para 23 of Memo No. Notification No. c) Validity of the Card upto 5. & date of enrolment 2. Disease 7. & date c) Sanctioning Authority 11. mention – a) Name of the beneficiary and relationship with pensioner b) Beneficiary’s Identification No. (ii)Copy of permission letter furnished : (For human organ implantation/ Dual-chamber pacemaker/ AICD/ CRT/ more than one drug eluting stents Implantation. Whether treatment was done in non-empanelled hospital If yes – a) Name of the hospital/nursing home with Clinical Establishment licence No. Details of advance sanctioned (if any) a) Amount b) Order No.) (Vide Para-8 & 9 of Finance Deptt. Entitlement of accommodation (Put tick mark) 6.05. Whether claim is for pensioner/family pensioner himself or his beneficiary. and address 9. etc. Period of treatment: a) OPD b) Indoor/Day Care treatment 10.] 1. Full name & designation (block letters) 3.West Bengal Health Scheme. Yes/No. . a)Treatment done within the State(i) Copy of intimation letter furnished : : : : : Private/Semi-Private/General ward : : : Yes/No : : from ________ to__________ from ________ to__________ : : : : Yes/No. 796-F (MED). 2008 FORM V Checklist For Reimbursement of Medical Claims [See sub-para (ii) of para 11 of memo no. 11. dated 31-01-2011) b) Treatment done outside the State – Copy of permission letter furnished : Yes/No. 3475 F dt. if for his beneficiary. (a) Name of office with address (b) Directorate (c) Department : : : : : 4.09. Pensioner’s/Family Pensioner’s Identification No. Name of the hospital where treatment was done/ to be done/ is going on 8. ... Yes/No. Yes/No. Yes/No....... The following documents are submitted (please tick [√] the relevant column)-(a) Photocopy of the Health Scheme identity Card of I) Govt..... 2008 12. Pensioner/family pensioner II) Beneficiary : : : : : : : : : : : : Yes/No.. etc. (for continuous OPD treatment) (b) If not.. : : : Yes/No. Dated. Yes/No Yes/No. Yes/No Yes/No (b) Essentiality Certificate (as specified) (c) Copy of discharge certificate (d) Copy of OPD prescription (e) Total Number of original bills & cash memos/ money receipts (f) Detailed list/Statement of medicines furnished (g) Detailed list of investigations furnished (h) Original papers have been lost the following documents are submitted(I) Photocopies of claim paper (II) Affidavit on stamp paper (III) Photo copy of Police Diary (i) In case of death of Govt... Yes/No.... Pensioner/ Family Pensioner following documents are submitted(I) Affidavit on stamp paper by claimant (II) No objection from other legal heirs on stamp papers (III) Copy of death certificate : : : Yes/No. Yes/No.. whether delay in preferring claim has been condoned by the West Bengal Health Scheme Authority under the Finance Department 13.... Signature of the Applicant ...West Bengal Health Scheme.. Yes/No.. (a) Whether the claim for reimbursement has been preferred within (i) three months from the date of discharge of indoor treatment (ii) three months from the date of consultation of OPD treatment (iii) three months from the date of purchase of medicines... Yes/No. 2008 with effect from __________________ He/She and his/her family members are entitled to the medical attendance and treatment in a Government Hospital/empanelled Private Hospital or Institution etc. if any Photograph (Stamp size) Name Age Relationship 2.05.VI Temporary Family Permit [See sub-para (vii) of para-7 of memo no.* Signature of Pension Sanctioning authority /Competent Authority. Name of the Govt.) Last designation Last Pay (Band Pay + Grade Pay)/ Basic Pension Entitlement of accommodation Date of Birth Date of retirement/ death Residential address Details of Family : : : : : : : : : Monthly income. This permit is valid for 6 (six) months from the date of enrolment*. 2008 in the entitled class mentioned in Sl. The temporary family permit is valid till the Government pensioner/ family pensioner gets P.O. No. Sl. 2. 4. 2008 FORM. . recognised under the West Bengal Health Scheme. No. No. 5. (P.P. ______________________________________________ last attached to _____________________________________________________________________ (office) under ________________________________________ Department/ family pensioner has been enrolled under the West Bengal Health Scheme. Shri/Smt. *Strike out whichever is not applicable. 4. 3. 5. 1. 6.P. 5. No. Pensioner/ Family Pensioner Pensioner Identification No. 3.09] 1. 7. 11.O. 9. 8.West Bengal Health Scheme. 3475-F dt.