Application Form For Grant Of Permission For Medical Treatment/ Diagnostic Tests From Hospitals/diagnostic Centres Empanelled Under Cghs.
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1LOK SABHA SECRETARIAT
WELFARE BRANCH
APPLICATION FORM FOR GRANT OF PERMISSION FOR MEDICAL TREATMENT/
DIAGNOSTIC TESTS FROM HOSPITALS/DIAGNOSTIC CENTRES EMPANELLED UNDER CGHS.
[Treatment/Test is to be taken after getting written permission from Welfare Branch]
1. Name of the Employee (in capital letters)
: Shri/Smt./Km._____________________________________
2. Designation
: ________________________________________________
3. Pay drawn in Pay Band
: Rs. _________________Grade Pay Rs.________________
4. Name of the Patient
: _________________________________________________
5. Relation with the Employee
: _________________________________________________
6. Details of Medical Treatment/Investigation advised by the Doctor:
Date of prescription slip (Mandatory)
7.
: _____________________________
(a)
Medical Treatment/ Investigation advised by [Please
CMO, CGHS Dispensary
() against the relevant head]
Specialist, Govt. Hospital
Authorised Medical Attendant
[for beneficiary not covered under CGHS]
(b)
Details of Medical Treatment/ Investigation advised
Name of the empanelled Hospital/Diagnostic
Centre where Medical Treatment/Diagnostic
test(s) is/are proposed to be undertaken
8.
Whether the Hospital/Diagnostic Centre where Medical Treatment/ Diagnostic test(s) is/are proposed to be
undertaken is/are empanelled for the procedure/test advised by the Doctor: Yes/No [Please ()]
9. To be filled in by the beneficiary covered under CGHS
(a) CGHS Card No.
(b) Name & Number of the Dispensary
10. To be filled in by the beneficiary not covered under CGHS
(i)
Name of the Authorised Medical Attendant (AMA) : Dr. __________________________
(ii)
Date upto which AMA has been appointed
:
__________________________
11. Documents to be enclosed:
(a) Copy of the prescription slip issued by the doctor.
[The name of the doctor, dispensary, date and stamp should be clearly visible and legible]
(b) Copy of CGHS Cards (both Employee and Patient).
(c) Copy of order of appointment of AMA [for beneficiary not covered under CGHS]
(d) Copy of Pay slip(Only for Treatment)
Signature
: _______________________
Branch
: _______________________
Tel. No.
: _______________________
Mobile (Optional)
: _______________________
Date
: _______________________
Forwarded to Welfare Branch
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