NATIONAL HEALTH MISSION, ASSAM
MEDICAL REIMBURSEMENT CLAIM FORM
Form of application for claiming refund of medical expenses incurred in connection with medical
attendance and/ or treatment of National Health Mission (NHM), Assam Employees and their families
for medical attendance/treatment taken from an Authorized Medical Attendant/ Hospital.
(NB: SEPARATE FORM SHOULD BE USED FOR EACH PATIENT)
1. EMPLOYEE DETAILS:
HRMIS ID :
NAME (in Block Letters) :
Designation :
State Level / District Level :
Date of Joining under NHM (dd/mm/yyyy) :
Original Place of Posting:
Present Place of Working :
(If attached, place of working & enclose attachment order)
Current Remuneration per month :
Present Address :
Permanent Address :
Mobile No. :
Marital Status ( tick mark) : (Single / Married / Widowed / Divorced / Separated)
2. PATIENT INFORMATION:
Name of the Patient :
Relationship to the NHM Employee :
Age of the Patient :
Medical Problem :
Claim submitted for Regular/ Emergent, Accident in Empaneled/ Non-Empaneled :
Whether the patient a Govt./ Retired Govt. employee ( tick mark) : (Yes / No)
(If Yes, Office/ Division in which employed)
3. CLAIM DETAILS:
Whether the Patient covered under AAA/ PMJAY? ( tick mark) (Yes / No)
If Yes, Registration No. :
Where the patient fell ill / met accident ?
Whether any Medical Reimbursement Claim submitted in the current Financial Year? ( tick mark)
(Yes / No)
Whether Re-imbursement/ Advance ?:
4. MEDICAL ATTENDANCE:
(i) Fees for consultation indicating :
(a)The name & designation of the medical :
Officer consulted and the hospital or dispensary
to which attached
(b) The number and dates of consultation and :
the free paid for each consultation
(c) The number & dates of injection and the :
fee paid for each injection
(d) Whether consultation and/or injections :
were had at the hospital, at the consulting room
of the medical officer or the residence of the patient
(ii) Charges for pathological, bacteriological, :
radiological or other similar tests undertaken during
diagnosis indicating
(a) The name of the hospital or laboratory where :
undertaken, and
(b) Whether the tests were undertaken on the :
advice of the authorised medical attendant
If so, a certificate to that effect should be attached
(iii) Cost of medicine purchased from the market :
(list of medicines, cash memos and the essentiality
certificates should be attached)
Name of the Hospital where treatment done ________________________________
Charges for hospital treatment indicating separately the charges for :-
(i) Accommodation :
(ii) Diet :
(iii) Surgical operation or medical treatment :
or confinement
(iv) Pathological, bacteriological, radiological :
or other similar tests indicating
(a) The name of the hospital or laboratory at :
which undertaken; and
(b) Whether undertaken on the advice of the :
medical Officer-in-charge of the case at
the hospital. If so, a certificate to that
effect should be attached.
(v) MEDICINES
(vi) Special medicines (list of medicine, cash :
memos and the essentiality cash should
attached)
(vii) Ordinary Nursing
:
(viii) Special nursing i.e. nurses, specially :
engaged for the patient. State whether
are employed on the advice of the medical
Officer-in-charge of the case at the hospital
or at the request of the NHM Employee or
patient. In the former case a certificate
from the medical Officer-in-charge of the
case and countersigned by the medical
superintendent of the hospital should be
attached
(ix) Ambulance charges (state the journey :
to_____________ and from ____________
undertaken)
(x) Any other chrges, e.g charges for electric :
light, fan, heater, air conditioning, etc
State also whether the facilities referred to are a part of the facilities normally provide to all patients
and no choice was left to the patient
III. CONSULTATION WITH SPECIALIST
Fees paid to a specialist or a Medical :
Officer other than the authorised medical
attendant indicating :-
a) The name and designation of the :
specialist or medical officer consulted
and the hospital to which attached
b) Number and dates of consultation and :
the fees charged for each consultation
c) Whether consultation was had at the :
hospital, at the consulting room of the
specialist or Medical officer, or at the
residence of the patient
d) Whether the specialist or Medical :
Officer was consulted on the advice of
the authorised medical attendant and the
prior approval of the Chief Administrative
Medical Officer of the State was obtained.
If so, a certificate to that effect should be
attached
NOTE: FILL ONLY APPLICABLE PART I &/OR II &/OR III
Total Amount Claimed Rs._______________________
Less Advance Taken on Rs.______________________
Net Amount Claimed Rs.________________________
List of enclosures Rs.________________________
DECLARATION TO BE SIGNED BY THE EMPLOYEE:
I hereby declare that the statements in the 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. In case of any false statement, I understand the amount may be released from me with interest
and I would be liable for any disciplinary action.
Dated: ___________________
(Signature of Employee) (Signature of Authority)
Name: Name:
Contact No.: Designation:
E-mail Address:
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FOR OFFICE USE ONLY:
We have examined the claim submitted by …………………………………………..and found the
facts true. We confirm the claim is genuine and recommend payment of Rs………………………. for
medical reimbursement as per provision of Office Memorandum (No. NHM-31016/2/2019-HRD-
NHM/26941 dated 09/01/2020).
District Admissibility Board Members:
(1) (2) (3) (4)
APPLY FOR MEDICAL REIMBURSEMENT:
To apply for medical reimbursement, the applicant should submit the medical reimbursement
proposal along with the following information:
DOCUMENT CHECKLIST:
For NHM Employee posted at District:
Recommendation from District Level Admissibility Board (seal & signature of the Members along
with Admissible amount by name of incumbent concerned is mandatory to furnish along with the
Admissibility Report).
Checklist:
Minutes of the meeting / Check List of the District Level Admissibility Board (seal & signature of the
Members alongwith Admissible amount by name of incumbent concerned is mandatory to furnish
along with the Admissibility Report)
Admissibility Report from the Jt. Director of Health Services (concerned district).
Authorized Medical Attendants recommendation (if applicable).
Referral Medical Board’s Certificate
Essentiality Certificate.
Discharge Summary/Certificate.
Records of Hospital, if applicable
Certificate from the Hospital authority.
Final bill / Bill summary issued by the Hospital authority.
Attested copy of Bank Pass Book.
Birth / Death Certificate (if applicable).
NOK / Legal Heir Certificate (if applicable).
Original bills/vouchers etc.
Leave order for the treatment period (if applicable).
A self declaration / undertaking of no claim from other sources.
Dependent certificate from concerned authority (if applicable).
Physical Verification Certificate of concerned D.D.O.
For NHM Employee posted at State HQ:
Recommendation State Admissibility Board (Seal & Signature of the Members along with
Admissible amount by name of incumbent concerned is mandatory to furnish along with the
Admissibility Report).
• Authorized Medical Attendants recommendation (if applicable).
• Referral Medical Board’s Certificate.
• Essentiality Certificate/ Identity proof of the patient along with documents showing relation with
the NHM Employee.
• Discharge Summary/ Certificate.
• Certificate from the Hospital Authority.
• Final Bill / Bill summary issued by the Hospital Authority.
• Attested copy of Bank Pass Book.
• Birth / Death Certificate (if applicable).
• Original Bills to be submitted with Seal & Signature for applying medical reimbursement.
• Leave order for the treatment period (if applicable).
• A Self Declaration / Undertaking of no claim from other sources.
• Dependent Certificate from concerned authority (if applicable).
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