Medical Reimbursement Claim Form for Railway Employee

Medical reimbushment claim form for railway employee could be downloaded by the option given below. Just follow the post and you will know the details of the claim form for medical Reimbursement.

Name of the Railway/Retd. employee (in BLOCK Letters) ____________________
2) Designation of Railway/Retd. employee (in BLOCK Letters) ____________________
3) Office & Station of employment ____________________
4) Pay/Last Pay of the Railway/Retd. Employee including grade pay ____________________
5) Residential address ____________________
6) MIC/RELHS no. & issuing Authority ____________________
7) MIC/RELHS register at H. Unit/Hospital ____________________
II A Name & Age of the patient ____________________
B Patient’s relationship to Rly./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 (Attached detailed bill): ____________________
F Weather Treatment was taken in Emergency: ____________________
G Are you a CTSE Member (Y/

IV Whether subscribing to any Health Insurance Policy or covered under any other health scheme:
If Yes, have you received any amount from the Insurance Company for the treatment in question? Give details if
any on a separate sheet of paper.
V Total Amount Claimed:
VI Details of Bank Account where Reimbursement is to be paid:
a) Name of Bank
c) Branch MIRC Code
b) Account No.
d) IFSC Code.
VII List of enclosures (Please Tick the documents attached and write additional documents)
A Photocopy of the MIC/RELHS Card
B Essentiality cum Emergency Certificate by the Non-Rly.
C Discharge Summary
D Original Bills of Hospital
E Original Cash Vouchers of Drugs/consumables/ Implants etc. if
F Outer Pouch of Stent, pacemaker, Implants
G Any other enclosures _____________________________________________
(In case of many enclosures, write a number of additional enclosures here and attach a separate sheet with
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 declared that this is my final claim and I shall not make any claim in the future to Railway
or any other health scheme with respect to this treatment episode.
Signature of the Railway employee
In case the beneficiary has a medical insurance policy and intent to make claim for the treatment in question then
he/she may make claim to the insurance company first and then submit a claim to Railway with documents, bills, etc.
attested by the insurance company

Medical Reimbursement Claim Form for Railway Employee pdf download

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