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    West Bengal Health Scheme, 2008 Form E: Checklist For Reimbursement of Medical Claims/ Sanction of Advance

    Uploaded by

    sudipta das
    - The document is a checklist form for employees in West Bengal seeking reimbursement for medical claims or advance sanction under the West Bengal Health Scheme, 2008. - The form requires information about the employee, beneficiary, hospital, treatment details, documents submitted, and whether claims are being filed within the proper timelines. - Employees must submit documentation like identity cards, bills, prescriptions, reports, affidavits and more, depending on the type of reimbursement or advance being sought.

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    West Bengal Health Scheme, 2008 Form E: Checklist For Reimbursement of Medical Claims/ Sanction of Advance

    Uploaded by

    sudipta das
    20 views2 pages
    - The document is a checklist form for employees in West Bengal seeking reimbursement for medical claims or advance sanction under the West Bengal Health Scheme, 2008. - The form requires information about the employee, beneficiary, hospital, treatment details, documents submitted, and whether claims are being filed within the proper timelines. - Employees must submit documentation like identity cards, bills, prescriptions, reports, affidavits and more, depending on the type of reimbursement or advance being sought.

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    Form-E

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    - The document is a checklist form for employees in West Bengal seeking reimbursement for medical claims or advance sanction under the West Bengal Health Scheme, 2008. - The form requires information about the employee, beneficiary, hospital, treatment details, documents submitted, and whether claims are being filed within the proper timelines. - Employees must submit documentation like identity cards, bills, prescriptions, reports, affidavits and more, depending on the type of reimbursement or advance being sought.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    20 views2 pages

    West Bengal Health Scheme, 2008 Form E: Checklist For Reimbursement of Medical Claims/ Sanction of Advance

    Uploaded by

    sudipta das
    - The document is a checklist form for employees in West Bengal seeking reimbursement for medical claims or advance sanction under the West Bengal Health Scheme, 2008. - The form requires information about the employee, beneficiary, hospital, treatment details, documents submitted, and whether claims are being filed within the proper timelines. - Employees must submit documentation like identity cards, bills, prescriptions, reports, affidavits and more, depending on the type of reimbursement or advance being sought.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    West Bengal Health Scheme, 2008

    FORM E
    Checklist for Reimbursement of Medical Claims/ Sanction of Advance
    (See sub-clause (3) of clause 12)

    1. Employee’s Identification No. & date of enrolment :

    2. Full name & designation


    (block letters) :

    3. (a) Name of office with address :

    (b) Directorate :

    (c) Department :

    4. Whether claim is for employee himself or his :


    beneficiary, if for his beneficiary, mention –

    a) Name of the beneficiary and relationship with employee :


    b) Beneficiary’s Identification No. :
    c) Validity of the Card up to :

    5. Entitlement of accommodation (Put tick mark) : Private/Semi-Private/General ward

    6. Disease :

    7. Name of the hospital where treatment was done/to be done


    /is going on :

    8. Whether treatment was done in non-empanelled hospital : Yes/No


    If yes –
    a) Name of the hospital/nursing home with Clinical
    Establishment licence No. and address :

    9. Period of treatment: a) OPD : from _________ to_________

    b) Indoor/ Day Care treatment : from _________ to_________

    10. Details of advance sanctioned -


    a) Amount :
    b) Order No. & date :
    c) Sanctioning Authority :

    11. a)Treatment done within the State-

    (i) Copy of intimation letter furnished : Yes/No.


    (Vide Clause-11 of the West Bengal Health Scheme, 2008)
    (ii)Copy of permission letter furnished : Yes/No.
    (For human organ implantation/ Dual-chamber pacemaker/
    AICD/ CRT/ more than one drug eluting stents Implantation,
    etc.) (Vide Para-8 & 9 of Finance Deptt. Notification No. 796-F
    (MED), dated 31-01-2011)

    b) Treatment done outside the State –


    Copy of permission letter furnished : Yes/No.
    West Bengal Health Scheme, 2008

    12. (A) Whether the claim for reimbursement has been preferred within

    (i) three months from the date of discharge of indoor treatment : Yes/No.
    (ii) three months from the date of consultation of OPD : Yes/No.
    treatment (iii) three months from the date of purchase of : Yes/No.
    medicines, etc. (for continuous OPD treatment)

    (B) If not, whether delay in preferring claim has been condoned


    by the West Bengal Health Scheme Authority
    under the Finance Department : Yes/No.

    13. The following documents are submitted


    (please tick [√] the relevant column)

    (a) Photocopy of the Health Scheme Identity Card of


    I) Govt. employee : Yes/No.
    II) Beneficiary : Yes/No

    (b) Essentiality Certificate (as specified) : Yes/No.

    (c) Copy of discharge summary : Yes/No.

    (d) Copy of OPD prescription : Yes/No

    (e) Total Number of original bills & cash memos :

    (f) Detailed list/Statement of medicines furnished : Yes/No

    (g) Detailed list of investigations furnished : Yes/No

    (h) Original papers have been lost the following documents are submitted-

    (I) Photocopies of claim papers : Yes/No.

    (II) Affidavit on stamp paper : Yes/No.

    (III)Photo copy of Police Diary : Yes/No.

    (i) In case of death of Govt. employee following documents are submitted-

    (I) Affidavit on stamp paper by claimant : Yes/No.

    (II) No objection from other legal heirs on stamp papers : Yes/No.

    (III) Copy of death certificate : Yes/No.

    Dated............................... Signature of the Applicant

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