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Esic Form 7b Word

This medical acceptance card documents an individual's application to be included in the list of patients for a specific doctor under the Employees' State Insurance Corporation program in India. It captures the applicant's name, family details, workplace, address and insurance/reference number. The applicant signs to confirm they are not already assigned to another doctor. The listed doctor then either accepts or rejects the individual for inclusion in their patient list by signing and providing their code number.

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Patil Hemant
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49K views1 page

Esic Form 7b Word

This medical acceptance card documents an individual's application to be included in the list of patients for a specific doctor under the Employees' State Insurance Corporation program in India. It captures the applicant's name, family details, workplace, address and insurance/reference number. The applicant signs to confirm they are not already assigned to another doctor. The listed doctor then either accepts or rejects the individual for inclusion in their patient list by signing and providing their code number.

Uploaded by

Patil Hemant
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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H.P. Cal.

-6/92/1,00,000 ESIC-MED-7B

MEDICAL ACCEPTANCE CARD

Full Name ...................................................................................................................

Father or Husband's Name .......................................................................................

Factory Name .............................................................................................................

Present Residential address

Ins. No./
Ref. No.

EMPLOYEES' STATE INSURANCE CORPORATION

I apply to be included in the list of Dr.........................................................


I declare that I am not already in the list of a doctor in this or any other
area.

Signature or thumb impression of


Date............................
Insured Person

To be completed by Doctor: Doctor's


Code No.

I accept this person for inclusion in my list

Date: Signature of the Doctor.

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