Application Form For Joining Relhs-97 & Issue Of Medical Card printable pdf download

APPLICATION FORM FOR JOINING RELHS-97 & ISSUE OF MEDICAL CARD

DIVISIONAL PERSONNEL OFFICER,

_____________________________

(Office from which Retired)

SIR,

SUBJECT: APPLICATION FOR JOINING RELHS-97 SCHEME & ISSUE OF MEDICAL CARD REFERNCE: RAILWAY

BOARD’S LETTER No. 2011/H/28/1/RELHS/Court Case Dated 31-5-2012 to all GMs

In reference to Railway Board’s letter cited above – vide which RELHS – 97 has been re-opened and made open

ended – I hereby opt to join & become member of RELHS-97 Scheme. Kindly issue me the Medical Card along with

that of my following dependent family members. My service particulars and other information are as under:

1. NAME: _______________________________________________

HUSBAND/FATHER’S NAME: _____________________________________________

DESIGNATION: _______________________________________________

OFFICE FROM WHICH RETIRED:

GRADE/ RATE OF PAY & PENSION_______________________________________________

DOB: _______________________________________________

DOA: _______________________________________________

DOR/DOD: ___________________________________________

NATURE OF RETIREMENT: _____________________________

10. M.R. NO. & DATE: _____________________________________

11. QUALIFYING SERVICE: ________________________________

12. ADDRESS & TELEPHONE NO: _______________________________________________

13. FIXED MEDICAL ALLOWANCE (RS 100) OPTED OR NOT: _________________________

14. NAME OF PENSION DISBURSING AUTHORITY i.e. (BANK): -

_________________________________________________________

ACCUNT NO. ______________________________________

15. PPO NO: _______________________________________________

16. DETAILS OF DEPENDENT FAMILY MEMBERS FOR WHICH MEDICAL CARD IS TO BE ISSUED:

SL NO

NAME

RELATION

DOB

DATE:PLACE:

JOINT PHOTOGRAPH OF

SIGNATURES OF APPLICANTNAME

FAMILY

OF APPLICANTDESIGNATIONDOR

PTO

DECLARATION REGARDING “LOCK-IN” PERIOD UNDER RELHS-97(REOPENING OF RETIRED

EMPLOYEES LIBERALISED HEALTH SCHEME-1997) I, ……………………………………………………… s/o Sh

……………………………………… retired on …………………………….. as …………………………………. hereby

declare that I am joining the above said scheme (RELHS-97) with full knowledge about the “LOCK IN”

period. I will not submit any reimbursement claim for treatment taken in private and private recognised

hospitals during the “LOCK IN” period (of 6 months); And also would not challenge the order of Railway

Board in this effect in any court of law. I also declare that I shall fulfill all terms and conditions in the

Railway Board’s Orders on RELHS – 97 as amended till now and bind with these instructions.

DATE:PLACE:

SIGNATURES OF APPLICANT ...............................

NAME OF APPLICANT ............................................

DESIGNATION/STATION ……………………….

DOR ……………………………..

ADDRESS ……………………………

……………………………………………………

DECLARATION OF FIXED MEDICAL ALLOWANCE

REG.: JOINING OF RETIRED EMPLOYEES LIBERALISED HEALTH (REOPEN) SCHEME-

I hereby declare that, I am residing at ……………………………………………………………………… …………………… &

drawing my pension from the Bank ……………………………………………. …………………………… Under PPO no

………………………… & Bank A/c no …………………... ……… I am getting* / not getting* Rs _____ pm as fixed medical

allowance since …………………………..

SIGNATURES OF APPLICANT............................................

DATE:PLACE:

NAME OF APPLICANT...............................................

DESIGNATION/STATION ……………………….

DOR ……………………………..

ADDRESS …………………………………….……………

………………………………………

*Strike out whichever is not applicable

Application Form For Joining Relhs-97 & Issue Of Medical Card

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