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Application Form

This document is an application form for medical aid under the Dr. Ambedkar Medical Aid Scheme. It requests information such as the patient's name, address, caste, age, sex, nature of disease, hospital where treatment is sought, estimated financial assistance required, annual family income, and whether assistance was received from other sources. The applicant must sign certifying the information is true, and the application must be forwarded by an MP, DM, DC, Health Secretary, or Social Welfare Secretary who recommends the patient.

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Rajat Sharma
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223 views2 pages

Application Form

This document is an application form for medical aid under the Dr. Ambedkar Medical Aid Scheme. It requests information such as the patient's name, address, caste, age, sex, nature of disease, hospital where treatment is sought, estimated financial assistance required, annual family income, and whether assistance was received from other sources. The applicant must sign certifying the information is true, and the application must be forwarded by an MP, DM, DC, Health Secretary, or Social Welfare Secretary who recommends the patient.

Uploaded by

Rajat Sharma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Application form forgetting Medical Aid under

Dr. Ambedkar Medical Aid Scheme

1. Name of the patient……………………………………………………………


2. Father/ Mother/ Husband/ Guardian…………………………………………..
3. Caste (Caste certificate to be attached)………………………………………..
4. Residential Address……………………………………………………………
…………………………………………………………………………………
5. Correspondence Address………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
6. Sex…………………………..
7. Age………………………….
8. Nature of disease………………………………………………………………
9. Name of the Hospital from where treatment is sought and whether it is
covered under the scheme……………………………………………………..
10. Financial assistance required (estimate certificate in original from hospital to
be attached)……………………………………………………………………
11. Annual income of the all adult members of family from all sources
(proof/certificate to be attached )……………………………………………..
12. Whether the applicant has taken such assistance from any other sources, if so
give details…………………………………………………………………….

It is certified that the information furnished above is true to the best of my knowledge
and belief and nothing has been concealed there from.

Signature of the applicant


(either self or legal guardian in case of minor)

Forwarded by_______________________________
(name, signature and seal of sitting M.P/D.M/D.C/Health/ Social Welfare Secretary
who recommends the patient

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