Reimbursement Claim Form

REIMBURSEMENT CLAIM FORM
1. Name of the Railway/retd. Employee (in BLOCK letter) ..................................................................
2. Designation of the Railway/Retd.employee (in BLOCK letters)…………………………………………………………………..
3. Office and Station of employment …………………………………………………………………….
4. Pay/Last Pay of the Railway/Retd.employee including Level …………………………………………………………………….
5. Residential address ………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………..
6. MIC/RELHS no. and issuing Authority ……………………………………………………………………….
7. MIC/RELHS registered at H Unit/Hospital …………………………………………………………………………
II.(A) Name and age of the patient ………………………………………………………………………..
(B) Patient’s relationship to the Railway/Retd.employee …………………………………………………………………………
III. Details of Indoor Treatment at Non Railway Institute …………………………………………………………………………
A.Name of Hospital: …………………………………………………………………………
B.Date of Admission: …………………………………………………………………………
C.Date of Discharge: ……………………………………………………………………….
D.Diagnosis: ……………………………………………………………………….
…………………………………………………………………………………….
E.Amount of Total Hospital Bill (Attach detailed bill): ……………………………………………………………………………………
F.Whether Treatment was taken in Emergency: ……………………………………………………………………….
G.Are you a CTSE member (Y/N): ……………………………………………………………………….
IV.Whether subscribing to any Health Insurance Policy or covered under any other health scheme;
If yes, have you received any amount from insurance company for the treatment in question. Give
details if any on separate sheet of paper.
V.Total Amount claimed:
VI.Details of Bank account where Reimbursement amount is to be paid
a.Name of Bank …………………………………………………………………. B. Account No…………………………………………….
b.Branch MICR Code…………………………………………………………… D.IFSC Code……………………………………………….
Contd-2
-2-
VII.List of enclosures (Please Tick the documents attached and write additional documents)
A. Photocopy of MIC/RELHS card
B. Essentiality cum Emergency Certificate by the Non, Rly, Hospital
C. Discharge Summary
D. Original Bills of Hospital
E. Original Cash Vouchers of Drugs/consumables/implants, etc, if relevant
F. Outer pouch of Stent, pacemaker, Implants, etc.,
G. Any other enclosure
………………………………………………………………………………………………………………………………………
(In case of many enclosures, write number of additional enclosures here and attach a separate
sheet with details)
DECLARATION TO BE SIGNED BY THE RAILWAY EMPLOYEE
I hereby declare that the statements in this application are true to the best of my knowledge and
belief and that the person for whom medical expenses were incurred is wholly dependent upon me.
I am aware that misuse of medical facilities or misrepresentation of any kind can attract penal
action including cancellation of MIC/RELHS Card. I hereby declare that this is my final claim and I
shall not make any claim in future to Railway or any other health scheme in respect to this
treatment episode.
………………………………………………………..
Signature of the Railway employee
Date ………………………………………..
Place ……………………………………….
In case the beneficiary has medical insurance policy and intend to make claim for the treatment in
question then he/she may make claim to insurance company first and then submit claim to Railway
with documents, bills, etc, attested by insurance company.

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ANNEXURE V
(See Para 659)
……………………………… RAILWAY
MEDICAL DEPARTMENT
ESSENTIALITY CERTIFICATE
I certify that Shri /Shrimati / Kumari …………………………………………………………………………………

Wife / Son/ Daughter of …………………………………………………………………………………… employed in the
……………………………………………………………… has been under my treatment for …………………………………
……………………………………………………………………. disease from …………………………………………………………..
to …………………………………………………………………….. at ……………………………………………………………………….
the ………………………………………………………… hospital/ my consulting room 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. The medicines are not
stocked in the ………………………………………………………………………………………………………………… hospital
and do not include proprietary preparations for which …………………………………………………………………….
hospital for supply to private patients cheaper substances of equal therapeutic value are
available, nor preparations, which are primarily foods, toilers or disinfectants.
Name of medicines Price
1. …………………………………………………………………………………………………….. ………………………….
2. …………………………………………………………………………………………………….. ………………………….
3. …………………………………………………………………………………………………….. ………………………….
4. …………………………………………………………………………………………………….. ………………………….
5. …………………………………………………………………………………………………….. ………………………….
………………………………………………………….
Signature of the Medical Officer
In charge of the case at the hospital
……………………………………………………………
Date ……………………………………….
Place ……………………………………….
Signature and designation of the

Authorized Medical Officer

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REIMBURSEMENT CLAIM FORM

1. Name of the Railway/retd. Employee (in BLOCK letter) ..................................................................

2. Designation of the Railway/Retd.employee (in BLOCK letters)…………………………………………………………………..

3. Office and Station of employment …………………………………………………………………….

4. Pay/Last Pay of the Railway/Retd.employee including Level …………………………………………………………………….

5. Residential address ………………………………………………………….

6. MIC/RELHS no. and issuing Authority ……………………………………………………………………….

7. MIC/RELHS registered at H Unit/Hospital …………………………………………………………………………

II.(A) Name and age of the patient ………………………………………………………………………..

(B) Patient’s relationship to the Railway/Retd.employee …………………………………………………………………………

III. Details of Indoor Treatment at Non Railway Institute …………………………………………………………………………

A.Name of Hospital: …………………………………………………………………………

B.Date of Admission: …………………………………………………………………………

C.Date of Discharge: ……………………………………………………………………….

E.Amount of Total Hospital Bill (Attach detailed bill): ……………………………………………………………………………………

F.Whether Treatment was taken in Emergency: ……………………………………………………………………….

G.Are you a CTSE member (Y/N): ……………………………………………………………………….

details if any on separate sheet of paper.

V.Total Amount claimed:

VI.Details of Bank account where Reimbursement amount is to be paid

a.Name of Bank …………………………………………………………………. B. Account No…………………………………………….

b.Branch MICR Code…………………………………………………………… D.IFSC Code……………………………………………….

A. Photocopy of MIC/RELHS card

B. Essentiality cum Emergency Certificate by the Non, Rly, Hospital

D. Original Bills of Hospital

E. Original Cash Vouchers of Drugs/consumables/implants, etc, if relevant

F. Outer pouch of Stent, pacemaker, Implants, etc.,

G. Any other enclosure

sheet with details)

DECLARATION TO BE SIGNED BY THE RAILWAY EMPLOYEE

Signature of the Railway employee

with documents, bills, etc, attested by insurance company.

I certify that Shri /Shrimati / Kumari …………………………………………………………………………………

Name of medicines Price

Signature and designation of the

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