MRC Document Checklist

ADDITIONAL INFORMATION

1.       Claim should be accompanied by a self-explanatory letter addressed to the Additional Director, CGHS, Pune stating the facts for direct admission without consultation of CGHS doctor.

2.       Revised MRC Form-S or Form-P as applicable duly filled in and signed by the applicant.

3.       Original Bills, cash memos of medicines, copies of investigation reports of various tests done at hospital or outside hospital, etc. Purchase vouchers for Implants (in orthopaedic cases).

4.       A consolidated list of cash memos/Receipts of medicines with total (Columns – cash memo No, Date, and Net Amount), purchased by patient (other than supplied by Hospital).

5.       Xerox copy of CGHS card – both sides.

6.       Discharge card of Hospital (Original)

7.       Emergency certificate of Treating doctor or hospital.

8.       A Xerox copy of CGHS case paper or paper of notebook of CGHS Wellness Center as a proof for admission o hospital is through CGHS Wellness Center.

9.       FOR ANGIOPLASTY/BY-PASS SURGERY CLAIM: IN addition to the above documents) (i) a copy of Angiography Report (ii) Purchase voucher of stent, sticker, and pouch.

10.   In case of CGHS cardholder expired – the claim may be made in the name of spouse and MRC form should be signed by spouse only.

11.   In case both cardholder and spouse have expired, legal heir should submit the claim in his/her name along with an affidavit from Notary on stamp paper of Rs. 100/ and No Objection Certificate from brother(s)/sister(s) including all above documents which are essential for normal claim.

12.   FOR HEARING AID CLAIM: (i) Revised MRC-P or MRC-S form, (ii) Advice letter for necessity of Hearing Aid from ENT Specialist of Govt. Hospital (Not from Audiologist), (iii) Xerox copy of Audiogram, (iv) Receipt of Purchase of Hearing Aid, (v) Xerox copy of CGHS Card Both sides, (vi) An undertaking stating that the beneficiary has not got any reimbursement for the cost of Hearing Aid in the preceding 5 years.

13.   Xerox copy of Bank passbook/statement showing IFSC, MICR Code of bank, Saving Account No. and Name of the claimant)

14.   A blank cancelled cheque.

 

v  Medical Claim should be submitted within three months from the date of Discharge/within three months of advice from ENT Specialist in case of Hearing Aid.

v  All Claim papers are to be submitted in duplicate.

v  Timing for Submission: 11 Am to 1 PM (Monday to Friday only)

 
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