Apply For Medical Help

Click Here to Download

INSTRUCTIONS FOR APPLICANTS SEEKING MEDICAL HELP:

(a) Forms not completely / correctly filled in, may not be considered.
(b) Please submit salary / income certificates of the applicant and family.
(c) Reimbursement will only be made against proof of payment of medical bills.
(d) Original bills and receipts required for verification and record.
(e) Only the applicant or close relative to submit the Form, along with all necessary documents.

PLEASE UPLOAD YOUR PHOTO

ADD CURRENT DATE

NAME OF THE PATIENT

NAME OF THE APPLICANT

ADDRESS OF THE PATIENT

TELEPHONE NO.

AADHAR CARD NO. OR PAN CARD NO.

AADHAR CARD OR PAN CARD (Attach signed copy)

NATURE OF ILLNESS AS DIAGNOSED

LETTER / CERTIFICATE FROM ATTENDING DOCTOR

IF HOSPITALIZED - DETALS OF THE HOSPITAL

HOSPITAL NAME

HOSPITAL TEL. NO.

HOSPITAL ADDRESS

TOTAL HOSPITALIZATION COST Rs.

MEDICAL BILLS WITH DOCTOR'S PRESCRIPTIONS TO BE ATTACHED, ALONG WITH DISCHARGE CARD. APPROPRIATE ORIGINAL BILLS WILL BE VERIFIED & MAINTAINED ON OUR RECORD

IF NOT HOSPITALIZED PLEASE STATE

APPROXIMATE COST FOR ENTIRE TREATMENT Rs.

ATTACH BILLS FOR CONSULTING FEES / CHEMIST BILLS, ALONG WITH DOCTOR'S PRESCRIPTIONS

DEPENDENT MEMBERS IN THE FAMILY (Please fill details below)

NAME

AGE

RELATIONSHIP

INCOME

NAME

AGE

RELATIONSHIP

INCOME

NAME

AGE

RELATIONSHIP

INCOME

STATE PARTICULARS OF HELP IF RECEIVED / EXPECTED FROM OTHER SOURCES

SOURCE 1

SOURCE 2

SOURCE 3

Total

I AGREE THAT THE INFORMATION GIVEN ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE

RECOMMENDATION: THIS APPLICANT IS WELL KNOWN TO ME

NAME OF RECOMMENDER

TEL. NO.

ADDRESS OF OFFICE / RESIDENCE