V.O. CHIDAMBARANAR PORT TRUST	
	CLAIM FORM FOR MEDICAL REIMBURSEMENT BILLS IN RESPECT OF WORKING EMPLOYEES	
Sl.No.	Details	Remarks	
1	Name of the  Employee		
2	Designation 		
3	Employee No.		
4	Medical ID No.		
5	Name of the Patient		
6	Relationship with Employee		
	a)  Self or Spouse		
 	b) Dependent		
7	In case of dependent of the Employee 		
	(i)Whether name has been enrolled in the Medical Identity Card		
	(ii) Date of Birth and Age of the Dependent (Copy of Medical ID card failing which details available in medisoft system to be enclosed)		
	(iii) Below 25 years/Above 25 years		
	(iv) Whether the monthly income is limited as per the CS (MA) rules i.e. Rs.3900/-+ amount of the Dearness relief on the basic Pension of Rs.3900/- as per pay revision orders for Port.	 --	
8	Name & place of the Hospital		
9	Period of Treatment		
10	Referral Hospital (or)                                                                     Non referral Hospital		
11	In case the treatment was at referral Hospital, whether the treatment was recommended by the Medical Department	 	
12	In case the treatment was at Non referral Hospital, whether  intimation was given by the Employee about the present treatment taken	YES   /  NO                                                                                                                                                                                                                                                                                                                                          If Yes, date of intimation & Copy of the Intimation to be enclosed	
13	Whether the Hospitalisation was due to Emergency situation or Normal 	 	
14	Total Bill Amount claimed	Rs.             /-	
		Rupees in words
    	
15	Enclosures                                                                                                  1.No of Original Bills                                                                  2.Medical reports                                                    3.Certificates(A&B)                                                                         4.Copy of Medical ID card or details in medisoft system                                                                                             5.Copy of the reference letter	 
	
I also declare that the information furnished above is true to the best of my Knowledge and belief.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              	
   Date:	 	SIGNATURE OF THE EMPLOYEE	
 	For the use of Medical Department	 	
16	Medical Department's  recommendation-whether the case is recommended for Reimbursement or Not	Yes   /  NO                                                                                                                       If Yes, admissibility of bill to be regulated under  CGHS Rates/ CSMA Rates                                                                                                                                                                                                                                         	
17	Admissible  amount as per CGHS rates 2014/ CSMA Rates	Rs.	
		Rupees in words
	
18	Prescribed format to show the admissiblity is enclosed	YES   /  NO                                                                                                                                                                                                                                                    	
19	For referral cases  the Competent Authority as per Sl.No 50 of Annexure(Non-Statutory) of DOP  Issued by Ministry vide letter No.17011/1/2005 PG, Dated:11.02.2015	Dy.CPT	
20	For Non referral cases, the Competent Authority as per  Sl.No.2(b) of revised DOP issued by Finance Department vide letter No.A-2/3/2013-Regns/D.1429 Dt.30.04.2014 	 	
	CMO              - Rs. 5000/- per claim		
	Dy.CPT         - Rs.25,000/- per claim		
	CPT                 - Full Powers		
21	Date of Receipt of Bill in Medical Dept	 	
22	Date of Receipt of Bill in Finance Dept	 	

	            

               Dy.CMO                        	A.O. Gr.II