APPLICATION FORM FOR CGHS CARD
Applying for New CGHS Card: In case of new pensioner's Card, the CGHS Beneficiary ID/ Card No. while in service
Applying for Plastic Card: Existing CGHS Beneficiary ID/ Card No.
1. Name of the Applicant in BLOCK letters:
2. Category: Departmental Serving Pensioner Others (PIs. specify) ……..................................
(Please tick Departmental if you are posted in the Ministry of Health & Family Welfare/ DGHS/ CGHS)
(Please tick Services if you belong to any specific organized service)
3. Name of Service/ Department:
4. Designation: Gazetted Non-Gazetted
5. Scale of Pay ………………………Present pay (Serving)……………………… Level (as per 7th CPC) …...............………......….
Last pay (Pensioner) Rs …………………………………………. Pre-Revised pay as per ...……… CPC: Rs …………………......….
6. Residential Address:
7. Official Address:
8. Telephone Number: (M) …….…………………………. (R)…………........….……………. (O) ………………………..……….......
9. E-mail ID: ……………………………………………………......................................................................……………………......….
10. Date of Superannuation: DD ….......................…… MM ……...............................… YYYY ………….................................….
11. Are you on Central Deputation (for Serving): YES/ NO
12. If yes, likely completion of Deputation: DD ….......................... MM ...........................… YYYY .............................…......……
13. Is your service transferable to other cities: YES/ NO
14 Details of Family (Including Self):
(* Please see definition of Family before filling up this column)
S. No. Relationship to CGHS Date of Birth
Name of Family members (Including Self) Aadhar Number
Card Holder * (DD-MM-YYYY)
Self
(* Please attach proof of age in case of sons)
16. Are all the person whose names have been mentioned above, dependent upon you and are they residing with you? (Please
attach proof of their staying with you like copy of Ration Card / Election ID / Passport / Identity Card issued by College/ School/
University Bank Pass Book, etc.)
17 Paste one ID Card size photograph of each member of family (including self), whose names are proposed to be included
as part of your family in the space given below. Each person's photograph should be attested by a Gazetted Officer in charge
of administration.
S.No: S.No: S.No: S.No:
Name: Name: Name: Name:
S.No: S.No: S.No: S.No:
Name: Name: Name: Name:
I undertake to intimate CGHS immediately if there is any change in dependency criteria of my family members included in this
application form. If I fail to intimate or if CGHS comes to know of the change, then the CGHS facility is liable to be withdrawn by
CGHS and CGHS/ appropriate authority will be free to initiate any action against me.
I undertake to surrender the CGHS cards on my leaving the Ministry/ Office on transfer/ retirement/ termination/ resignation or on
ceasing to be eligible for CGHS benefits.
I certify the information furnished by me in this application to be correct and that no information has been concealed or has been
misrepresented and I stand by the same.
BHARATKOSH RECEIPT DETAILS
Transaction Ref. No……………….…….……………… Date and time ……………….………
Rs…………………… (Copy of Receipt enclosed).
Date:
Place: Signature of the Applicant
To Be Filled by the Sponsoring Authority (in case of Serving employees)
The information furnished by the applicant has been verified and found to be correct. It is recommended that a CGHS Card be issued
to Shri/Smt/Kumari............................................. Designation………………………. retired from ................................................... in
this ministry/Department/Organization. Instructions are issued to the concerned Division to start deducting CGHS subscriptions
every month from the salary of the applicant/CGHS Subscriptions are deducted every month from the salary of the applicant. I am
the authorized sponsoring authority for the issue of CGHS Cards and approval of the competent authority has been obtained.
Date: Signature & Name of Sponsoring Authority
Place: Designation (Stamp) with Tel. Number
Verified by Authorized Signatory, CGHS (HQ) Signature of Additional Director/CMO HQ
Signature with Official Seal Designation (Stamp)
The Following Documents are to be enclosed:
1.Proof of Residence/Stay of dependents (copy of Ration Card I Election ID / Passport / Identity Card issued by College /
School/University / Bank Passbook, etc.)
2. Proof of age of son/Disability Certificate
3.Attested Copy of Disability certificate issued by Competent Authority (in case of dependent son aged 25 and
above.
4.Surrender Certificate of CGHS card while in service
5.Attested copies of PPO/ Last Pay Certificate Contribution by Pensioners
6.Pension Certificate from pension drawing authority indicating one-month pension details and whether the pensioner is
drawing the medical allowance or not.
7.Aadhar card of each beneficiary.
8.All the photographs need to be attested by a Gazetted Officer in charge of administration.
9.Bharat Kosh transaction receipt. All the receipts of the Government of India shall be done through bharatkosh.gov.in under
Non-Tax Receipt Portal only. Henceforth, all the receipts towards CGHS subscriptions from pensioners for issue of pensioner
card, renewal of cards and issue of duplicate cards shall be received through Bharat Kosh in NTRP only. No Demand Drafts,
IPOs shall be received by CGHS Bangalore. Visit CGHS Bangalore website (cghsbng.gov.in) for the steps to pay CGHS
subscription online.
Instructions
Definition of Family
1. Husband / Wife (First wife only)
2. Dependent Parents / Step Mother (in case of adoption, only adoptive & not real parents)
3. If adoptive father has more than one wife, the first wife only.
4. A female employee has a choice to include either her dependent parents or her dependent parents – in law; option
exercise can be changed only once during service.
5. Children including legally adopted children, step children and children taken as wards subject to the following conditions:
(i) Son Till he starts earning or attains the age of
25 years, whichever is earlier.
(ii) Daughter Till she starts earning or gets married,
irrespective of the age limit, whichever may
be earlier
(iii) Son Suffering from any permanent disability of any kind Irrespective of age limit.
(physical or mental) as defined below
(iv) Dependent divorced / abandoned or separated from their
husband / widowed daughters and dependent unmarried
/ divorced abandoned or separated from their husband / Irrespective of age limit.
widowed sisters.
(v) Dependent Minor brother(s) Up to the age of becoming a major.
For the purpose of availing CGHS facility for a disabled son above 25 years, please attach a copy of the certificate of
disability issued by the competent authority.
“Disability” will be AS DEFINED IN SECTION 2(1) OF THE PERSONS WITH DISABILITIES (EQUAL OPPORTUNITIES,
PROTECTION OF RIGHTSAND FULL PARTICIPATION) ACT ,1995 (NO: 1 OF 1996) WHICH IS REPRODUCED BELOW:
“DISABILITY MEANS
I. BLINDNESS
II. LOW VISION
III. LEPROSY CURED
IV. HEARING IMPAIRMENT
V. LOCOMOTIVE DISABILITY
VI. MENTAL RETARDATION
VII. MENTAL ILLNESS
Dependency:
Members of family (other than spouse) whose income is less than Rs.9000/ plus the amount of dearness relief on basic pension
of Rs. 9000/- as on the date of consideration are treated as dependents and are normally residing with CGHS beneficiary.
