Scribd Logo
Upload

Welcome to Scribd!

  • 70 views

    WBHS Ipd App Form Emp

    Uploaded by

    Souvik Das
    1. The document is a reimbursement claim form submitted by MD Hasanujjaman for Rs. 29,880 for his wife Baisakhi Biswas' treatment at Lila Hospital Pvt. Ltd. from June 21-25, 2020. 2. The claim includes Rs. 3,840 for room rent, Rs. 1,600 for consultation fees, Rs. 15,920 for tests and scans, Rs. 6,290 for medicines, Rs. 1,630 for consumables, and Rs. 600 for miscellaneous charges. 3. Hasanujjaman declares the claim is true and encloses documents like bills, receipts, discharge summary to substantiate the claim

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    WBHS Ipd App Form Emp

    Uploaded by

    Souvik Das
    70 views3 pages
    1. The document is a reimbursement claim form submitted by MD Hasanujjaman for Rs. 29,880 for his wife Baisakhi Biswas' treatment at Lila Hospital Pvt. Ltd. from June 21-25, 2020. 2. The claim includes Rs. 3,840 for room rent, Rs. 1,600 for consultation fees, Rs. 15,920 for tests and scans, Rs. 6,290 for medicines, Rs. 1,630 for consumables, and Rs. 600 for miscellaneous charges. 3. Hasanujjaman declares the claim is true and encloses documents like bills, receipts, discharge summary to substantiate the claim

    Original Title

    WBHS_IPD_APP_FORM_EMP

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1. The document is a reimbursement claim form submitted by MD Hasanujjaman for Rs. 29,880 for his wife Baisakhi Biswas' treatment at Lila Hospital Pvt. Ltd. from June 21-25, 2020. 2. The claim includes Rs. 3,840 for room rent, Rs. 1,600 for consultation fees, Rs. 15,920 for tests and scans, Rs. 6,290 for medicines, Rs. 1,630 for consumables, and Rs. 600 for miscellaneous charges. 3. Hasanujjaman declares the claim is true and encloses documents like bills, receipts, discharge summary to substantiate the claim

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    70 views3 pages

    WBHS Ipd App Form Emp

    Uploaded by

    Souvik Das
    1. The document is a reimbursement claim form submitted by MD Hasanujjaman for Rs. 29,880 for his wife Baisakhi Biswas' treatment at Lila Hospital Pvt. Ltd. from June 21-25, 2020. 2. The claim includes Rs. 3,840 for room rent, Rs. 1,600 for consultation fees, Rs. 15,920 for tests and scans, Rs. 6,290 for medicines, Rs. 1,630 for consumables, and Rs. 600 for miscellaneous charges. 3. Hasanujjaman declares the claim is true and encloses documents like bills, receipts, discharge summary to substantiate the claim

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 3

    Form - C2

    Reimbursement for cost of In-Patient Department (IPD) treatment in Non-Empanelled


    Hospital/Nursing Home/Health Care Organisation Under West Bengal Health Scheme
    (As per Order No.127-F(MED)WB, dated 26.11.2021)
    (Generated by Employee from Health Portal)

    To
    The OFFICER IN CHARGE
    P.O. SHEIKHPARA, P.S. RANINAGAR, DIST. MURSHIDABAD, WEST BENGAL, PIN -
    742409.
    Sir / Madam,
    I am submitting a claim of Rs. 29880 (Rupees. Twenty Nine Thousand Eight Hundred and Eighty ) towards
    reimbursement for cost of In-Patient Department (IPD) treatment at non-empanelled hospital/nursing home/health
    care organisation under West Bengal Health Scheme as per details stated below:

    Part-I[General Information]
    1. Details of Employee.
    Full Name MD HASANUJJAMAN HRMS ID 2013000614
    Enrolment ID No. WB/EMP/03/000064808 Claim Application ID E20212002081
    Bed Entitlement SEMI-PRIVATE Date of Enrolment 01/03/2014
    2. Details of Patient, Treating Hospital and Condonation Requirement, if any.
    2.1 Name of Patient BAISAKHI BISWAS
    Beneficiary ID EDN/WB/26183/4/4
    Relationship with Employee WIFE

    Name of the hospital where


    2.2 LILA HOSPITAL PVT. LTD.
    treatment was availed.
    Bed Capacity of Hospital 100
    CE Licence No. 33322840
    CE Licence valid up to 04/04/2022
    Address of Hospital 13/3/A, A. C. ROAD, P.O.-KHAGRA, P.S.-
    BERHAMPORE, MURSHIDABAD
    2.3 Requirement of approval of delay NO
    Condonation, if any
    3.Details of Claimant (Applicable in case of death of employee )
    Sl. No. Name of Claimant Relation
    3.1
    Part-II [Details and Expenditure Statement of IPD treatment]
    ϰ͘WĞƌŝŽĚŽĨƚƌĞĂƚŵĞŶƚ
    Admission Date 21/06/2020 Discharge date 25/06/2020
    5. Type of Discharge
    Tick mark in Type of Tick mark in
    Sl. No. Type of Discharge Sl. No.
    appropriate box Discharge appropriate box
    5.1 Normal ; 5.3 Referral †
    5.2 Risk Bond † 5.4 Death †
    Form - C2
    Reimbursement for cost of In-Patient Department (IPD) treatment in Non-Empanelled
    Hospital/Nursing Home/Health Care Organisation Under West Bengal Health Scheme
    (As per Order No.127-F(MED)WB, dated 26.11.2021)
    (Generated by Employee from Health Portal)
    ϲ͘ŵŽƵŶƚůĂŝŵĞĚĨŽƌ
    Tick mark in
    Sl. No. Type of Treatment
    appropriate box
    6.1 Only Procedural/ Package Treatment †
    6.2 Only Non-Procedural/ Non-Package Treatment ;
    6.3 Both Procedural/ Package and Non- Procedural/ Non-Package Treatment †
    ϲ͘ϭĞƚĂŝůƐŽĨWƌŽĐĞĚƵƌĂůͬWĂĐŬĂŐĞdƌĞĂƚŵĞŶƚ

    Period of Procedural/Package Treatment From 01/01/1900 To 01/01/1900

    ϲ͘ϯĞƚĂŝůƐŽĨEŽŶͲWƌŽĐĞĚƵƌĂůͬEŽŶͲWĂĐŬĂŐĞdƌĞĂƚŵĞŶƚ
    Period of Non-Procedural/Non-Package Treatment From 21/06/2020 To 25/06/2020
    ϲ͘ϯ͘ϭZŽŽŵͬĞĚZĞŶƚ
    Room Type From To Amount Claimed (Rs.)
    SEMI-PRIVATE 21/06/2020 25/06/2020 3840

    6.3.2 Consultation Fees 1600

    6.3.3 Pathological and Radiological Investigations 15920

    6.3.4 Medicines 6290

    6.3.5 Consumables 1630

    6.3.6 Special Nursing/Ayah Charges


    6.3.7 Miscellaneous. (If Any Specify) 600

    Total- 29880

    No. of Vouchers- 01

    Total Treatment Cost [6.1+ 6.2+6.3]- 29880

    Part-III [Details of Discount and Insurance Coverage]


    7. Details of Discount and Insurance Coverage, if any
    Sl. No Particulars Amount (Rs.) Remarks
    1. Discount
    2. Insurance Coverage
    Net Claim : (Part-II minus Part-III)
    29880 Twenty Nine Thousand Eight Hundred and Eighty Only
    Part-IV [Declaration of Employee]

    I hereby declare that the statements made in the application of claim for reimbursement are true to
    the best of my knowledge and belief. The person, for whom medical expenses are incurred, is a
    beneficiary of West Bengal Health Scheme and possessed a valid enrolment certificate at the time
    treatment. I will be held responsible and liable to face any disciplinary action taken against me in terms of
    WBS (CCA) Rules 1971 if the claim is found false and malafide due to any suppression of facts. I am
    enclosing the following instrument(s) to substantiate my claims in sequential manner.
    Form - C2
    Reimbursement for cost of In-Patient Department (IPD) treatment in Non-Empanelled
    Hospital/Nursing Home/Health Care Organisation Under West Bengal Health Scheme
    (As per Order No.127-F(MED)WB, dated 26.11.2021)
    (Generated by Employee from Health Portal)

    [List of Enclosures]
    Sl. No. Name/Particulars of enclosures to be attached Enclosed or not(Please Tick)
    Annexure-II duly signed with proper stamp by the Medical
    Superintendent or Administrative Officer of the Non-
    1. Yes † No †
    Empanelled Hospital/Nursing Home/Health Care Organisation
    where treatment availed.
    2. Bill Summary Yes † No †
    3. Original Money Receipts in chronological dates Yes † No †
    Copy of Discharge Summary (Case summary and copy of death
    4. Yes † No †
    certificate in case of death) and OT note
    5. Detailed Bill Yes † No †

    6. Original copy of Voucher/ Tax Invoice of Implants Used Yes † No †

    Copy of investigation/ test report in sequentially


    7. Yes † No †

    Copy of OT Note in case of package treatment and treatment


    8. summary or bed head ticket in case of package treatment Yes † No †

    In case of death of Employee,


    a. An affidavit on stamp paper by claimant Yes † No †
    9. Yes † No †
    b. No objection from other legal heirs on stamp papers Yes † No †
    c. Copy of death certificate
    10. Any other instruments (Specify) Yes † No †

    Date:
    Signature of the Employee/Claimant:

    Name in Block Letters :

    Designation :

    You might also like

    pFad - Phonifier reborn

    Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

    Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


    Alternative Proxies:

    Alternative Proxy

    pFad Proxy

    pFad v3 Proxy

    pFad v4 Proxy