Medical Reimbursement Form for Railway Employees and Railway Pensioners

Medical Reimbursement Form for Railway Employees in Service and for pensioners under RELHS – To be used for external hospitals

Northern Railway has published the Reimbursement Form for claiming the medical expenses incurred for Railway Employees, under RELHS and their dependants at Hospitals other than Railway Hospitals or mobile health units of Railway.

CHECKLIST FOR REIMBURSEMENT CASES

  1. Medical card/RELHS medical card photocopy duly attested by gazetted officer.
  2. (A) Referred Slip
    (B) For non-referred cases Application of employee describing the condition of the patient and circumstances for going directly to non-railway hospital.
  3. Discharge slip in original
  4. Bills Vouchers (In original)
    (Duly countersinged by treating Doctor)
  5. Summary of bills in serial number/date wise as given in reimbursement claim form, foot note 2 (f) (duly countersigned by treating Doctor and countersigned by AMO).
  6. Essential certificate (signed by treating Doctor and countersigned by Medical Supdt./incharge of the hospital.
  7. Medical reimbursement form duly signed by employee and controlling officer.

 

Checked and found O.K.,

Sign. of Dealing Clerk of Medical Deptt.
Regn. No.

Date

Note:- Without above enclosures form will not be accepted

NORTHERN RAILWAY

Annexure ‘A’ to letter No. 494-E/O VII/E IV, dated 29-2-99/31-3-99

MEDICAL REIMBURSEMENT FORM

  1. Name of Employee/Ex. Employee  : ………………………………………………………….
  2. Whether serving or retired             : ………………………………………………………….
  3. Designation                                   : ………………………………………………………….
  4. Office/Unit of posting                    : ………………………………………………………….
  5. Pay & Scale .of Employee/Pay last drawn in case of ex-employee. : ………………………………….
  6. Name of Patient : ………………………………….
  7. Relationship with railway employee for whom reimbursement is claimed. : ………………………………….
  8. Age of Patient : ………………………………….
  9. Medical/RELHS I/Card No. : ………………………………….
  10. Whether referred or non referred : ………………………………….
  11. If referred by whom ? : ………………………………….
  12. Name of the institution where treatment is taken : ………………………………….
  13. Date of admission : ………………………………….
  14. Date of discharge : ………………………………….
  15. Reasons for delayed, submission of claim, it delayed for more than 6 months. : ………………………………….
  16. Total period of stay as indoor patient : ………………………………….
  17. Reasons for long stay (if stayed for more than 48 hrs.) : ………………………………….
  18. Type of medical emergency
  19. Was there no Railway/Govt/facility available to deal it ? : ………………………………….
  20. Distance of the nearest Govt. Hospital & whether facilities available there.
  21. Distance of the nearest Rly. Hospital & whether facilities
  22. available there. If not, how far is the Railway Hospital with the facilities available.
  23. Distance of the Private Hospital from residence/Place of illness, where facilities availed.
  24. When the Railway Medical Officer was informed about such admission ?
  25. Did the patient take any treatment before or after for the present sickness (if this existed before). and if yes, when ?
  26. Total amount claimed (with break-up of charges) (detailed instructions at (f) of foot note below).
  27. Total number of enclosures.
  28. Employee’s residential address
  29. Place/Address of falling sick
  30. Phone No.

 

Counter sign of Controlling Officer/Unit Incharge                                          Signature of Employee/ Ex-   Employees/Spouse

(in case of serving employees only) ·

Declaration to be signed by the person claiming Medical Reimbursement :-

I hereby declare that the statement in this application are true to the best of my knowledge and belief and

(i) That the person for whom medical expenses were incurred is wholly dependent upon me.

(ii) The medical expenses were incurred for self.

(Strike-out what is not applicable from (i) & (ii) above)

Date:

Place:

Signature of Rly. Servant/

Designation and office to which attached

Foot-note

  1. Item No. 18! 19, 20, 21, 22, 23, 24 & 25 are applicable only for non-referred cases.
  2. Following documents should be attached with this proforma :-(i) Employees/Retired Employees Application giving circumstances under which he/she took treatment.(ii) Photo copy of Medical/RELHS I.D. Card (duly attested by a Gazetted Officer)

    (iii) Essentiality certificate issued by the treating doctor of hospital countersigned by Medical Supdt. of the treating hospital.

    (iv) Discharge certificate/slip in original.

    (v) Bills/Vouchers (in original) duly countersigned by treating officer (Authorised M.O.)

    (vi) Detailed item-wise break-up of all-the bills (this means all bills/vouchers submitted at (v) above should be reproduced in Legible manner) for e.g. :-.Bill No……… Name of Chemist/Shop…………………..Date …………….

S.No. Description of item Oty. Price

Rs. P.1.   2.   3.   4.

Total

 

 

(vii) In case of referred cases, attach original referred slip.

(viii ) Instruction for submission :-

In referred cases, the application duly countersigned by Controlling Officer/Subordinate Incharge should be submitted to the Medical Establishment from where he/she was referred.

In un-referred cases, the application duly countersigned by Controlling Officer/Subordinate Incharge should be submitted to the ‘P’ Branch concerned, to the cell set-up for the purpose of handling Medical Reimbursement case.

 (For Official Use only)

ln case of all cases being sent to Board.

In case of AGM’s sanction for unreferred/Non Govt. unrecognised cases.

  1. Verbatim view of C.M.D.
  2. Verbatim view of FA & CAO
  3. Signature of C.P.O.

DETAIL OF DATE WISE/ITEM WISE BREAK UP OF ALL THE BILLS OF

(Name of Patient……… . ….. )

Sr No Date Bill No Name of Chemist/Firm Description of Item . Quantity Price

Signature of the Medical Officer                                                   Signature of the Medical Officer/Incharge of

the case of the Hospital

 

See Para

MEDICAL DEPARTMENT

ESSENTIAUTY CERTIFICATE

 

……………………………wife Son/daughter of……………………………………..of……………….

the……………………………. . hospital for……. .. disease from . . . .. . .. to ………………………….

and that the under mentioned medicines prescribed by me in this connection were essential for the recovery/prevention of serious deterioration in the condition of the patient.

for supply to private patients cheaper substances of equal the terapeutic value are available, nor preparations, which are primarily foods, toilets or disinfectants. ·

 

No.                   Name of Medicines               Price

 

…………………………………….

Signature & Designation of the Authorized

Medical Officer

Date: ..

Place: .

 

Signature of the Medical Officer/Incharge

of the case of the Hospital

 

Download Northern Railway Medical Reimbursement Form

Download Railway Board instruction all Medical Units of Railways on Emergency Treatments taken other than their Registered Unit

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