ANNEXURE-2

To be filled (With each claim) in case of “Outdoor” Treatment.

1. Name
2. Staff No.
3. Unit where working
4. Data of joining Mobile Services
(Only for those who have joined
in current financial year)
5. Basic pay (attach pay slip of the
month of March of previous
Financial year)

CHECKLIST
(Indicate as yes or no)
1. *Whether submitted copy of Ration
Card or any other documentary
Proof in support of declaration
Of family members
2. *Whether CGHS card has been
submitted or not
3. * Stamp of consultant
on the prescription
4. * Sign on the back of cash memo
5. *Whether doctor’s name is clearly
mentioned on the cash memo or not
(Cash memo without consultant name
will be rejected)
6. *Whether Reports for laboratory
tests are attached or not
* These formalities are must be essentially fulfilled other wise claim will be out rightly
rejected

CERTIFICATE
I hereby declare that
1. The above information is correct.
2. The family members for whom medical claim is sought are fully dependent on me and
there income is not more that Rs.1500/- per month.
3. My husband/wife is employed/ not employed in Central Govt./Semi Govt./PSU and I have
not claimed medical reimbursement form anywhere else.
4. I have received quarterly payment as under

Period of quarterly Amount in Rs.

payment
January
April to June
July to September
October to
December

Signature of Official Signature Unit Officer (With Stamp)

 ANNEXURE-1 (A)
For outdoor treatment only

MAHANAGAR TELEPHONE NIGAM LIMITED

OFFICE OF THE CHIEF GENERAL MANAGER TELEPHONES, K.L.BHAWAN NEW DELHI
–50

This is to certify that the following members of my family have taken the treatment.

S.NO Patient’s Name Doctor’s Name Relationship Suffering from Period of

treatment
1

S.No. Patient’s Name Amount Amount (total) Cash Memo Numbers

Consult. Cash memo Tests

My claim is for a total sum of

Consultation (Total) Rs.__________________________

Cash Memo (Total) Rs.__________________________
Test (Total) Rs.__________________________
Grand Total Rs.__________________________

I certify that the claim is true and correct and of dependents upon me.
My Basic Pay is Rs._____________________
Name:
Designation & Staff No.
Office Address
Telephone No.

Signature of the Govt. servant

And office to which attached
 (For office use only)

CLAIM SCRUTINISED

After disallowing in admissible items, it has been admitted, please pay

Rs.________________(Rupees________________________________only)

to Sh. /Smt/Kumari _____________________________________________

Controlling authority

Progressive Total:__________________

Head of Account:___________________

Fund are available:_________________

Received Payment

Signature

 Portion not required should be deleted.

 Submission of proof of family members and pay slip of the month of

March is necessary with first bill in a financial year.