WBHS Opd App Form Emp

Form - C1
Reimbursement for cost of Out-Door Patient (OPD) treatment in

Recognised/Empanelled /Enlisted Hospital Under West Bengal Health Scheme
(As per Order No.127-F(MED)WB, dated 26.11.2021)
(Generated by Employee from Health Portal)
To
The OFFICER IN CHARGE
Tehatta, Nadia- 741160
Sir / Madam,
I am submitting a claim of Rs. 5400 (Rupees. Five Thousand Four Hundred ) towards reimbursement for cost of Out-
Patient Department (OPD) treatment at recognised / empanelled / enlisted hospital under West Bengal Health Scheme
as per details stated below:
Part-I[General Information]
1. Details of Employee.
Full Name PALLABI CHATTERJEE HRMS ID 2020000515
Enrolment ID No. WB/EMP/04/000364188 Claim Application ID E20231001720
Bed Entitlement SEMI-PRIVATE Date of Enrolment 01/05/2021
2. Details of Patient, Treating Hospital and Condonation Requirement, if any.
2.1 Name of Patient PALLABI CHATTERJEE
Beneficiary ID EDN/WB/29369/1/2
Relationship with Employee SELF
Name of
2.2 Recognised/Empanelled/Enlisted MEDICA SUPERSPECIALITY HOSPITAL
hospital where treatment is availed.
Code of Hospital 0411034
Class of Entitlement of Hospital Class-1
Address of Hospital 127,MUKUNDAPUR,EM BYE PASS,KOLKATA-
700099
2.3 Requirement of approval of delay NO
Condonation, if any
3.Details of Claimant (Applicable in case of death of employee )
Sl. No. Name of Claimant Relation
3.1
4.Permission Details, If any
Sl. No. Permission sought for Details of permission approval
4.1 For treatment availed in enlisted hospital DĞŵŽEŽ͗͘
outside West Bengal(see clause 14 of -----------------------------------------------------------------
order no.7287, dated 19.09.2008). ĂƚĞ͗
-----------------------------------------------------------------
ĞƐŝŐŶĂƚŝŽŶͬƵƚŚŽƌŝƚǇ͗
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U.O. No. and date of
Finance Deptt.West Bengal, if any :
Part-II [Details and Expenditure Statement of OPD treatment]

Form - C1
5. Details of OPD Treatment
Sl. No. Particulars Details
Category of OPD Claim (Tick mark in As per clause 7(1) of ϳϮϴϳʹF, dated : 19-09-2008
appropriate box) [See list of
5.1
diseases/illness mentioned in clause 7
(1) and 7(2)]
5.2 Name and Nature of OPD Disease/ Selected Investigations [ Vide para 10 of 797-F(MED),
Illness or follow-up medical dated 31.01.2011] , Continuous
attendance and treatment
5.3 Date of OPD/Follow Up consultation 01/04/2024
6. Expenditure Statement of OPD/Follow Up treatment
Sl No. Name of Component Amount Claimed (Rs.)
6.1 Procedure Charges
Amount Admissible
Sl No. Name of Procedure Procedure Code
(Rs.)
6.2 Consultation Fees
6.3 Cost of Pathological and Radiological Investigations
Name of Coded / Non- Code of Amount
Sl No. 5400
Investigation Coded Investigation Admissible (Rs.)
1 MRI LOWER
Coded 02029036 5400
ABDOMEN/PELVIS
6.4 Cost of Medicines
Period of post consultation From To
medicine consumption
6.5 Cost of Implant / Prosthesis & Special Device
Name of Implant /
Code of Implant / Amount
Sl No. Prosthesis & Special 0
Prosthesis & Special Device Admissible (Rs.)
Device
6.6 Miscellaneous
Total 5400
No. of vouchers 01
Net Claim:
5400 Five Thousand Four Hundred Only
Part-V [Declaration of Employee]

I hereby declare that the statements made in the application for claim are true to the best of my
knowledge and belief. The person, for whom medical expenses are incurred, is a beneficiary of West
Bengal Health Scheme and possessed a valid enrolment certificate at the time treatment. I will be
personally responsible and liable for taking disciplinary action in terms of WBS (CCA) Rules 1971 if the
claim finds false and malafide due to any suppression of facts. I am enclosing the following instrument
to substantiate my claims in sequential manner.
Form - C1
[List of Enclosures]
Enclosed or not (Please

Sl. No. Name/Particulars of enclosures to be attached
Tick)
Annexure-I duly signed with proper stamp by Treating
Consultant/Specialist of a Recognised/Empanelled/Enlisted Hospital
1. Yes No
or copy of duly signed and stamped Annexure-I (See notes of
annexure-I carefully).
2. Original Money Receipts in chronological dates Yes No
3. Copy of OPD prescription Yes No
4. Copy of Permission grant if any Yes No
5. Original copy of Voucher/ Tax Invoice of Implants purchased Yes No
6. Copy of all investigation/ test reports in sequentially. Yes No
Essentiality supported with prescription and audiometric report from
treating recognised/empanelled hospital/diagnostic centre
7. Yes No
(Applicable only for claiming reimbursement of Prosthesis and
Special Devices).
In case of death of Employee,
a. An affidavit on stamp paper by claimant Yes No
8. Yes No
b. No objection from other legal heirs on stamp papers Yes No
c. Copy of death certificate
9. Any other instruments (Specify) Yes No
Date: Signature of the Employee/Claimant:
Name in Block Letters :
Designation :

WBHS Opd App Form Emp

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Form - C1

Reimbursement for cost of Out-Door Patient (OPD) treatment in

Part-II [Details and Expenditure Statement of OPD treatment]

Part-V [Declaration of Employee]

Enclosed or not (Please

Date: Signature of the Employee/Claimant:

Name in Block Letters :

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