Annexure I to OM 2009

Medical

15 Mar 2026

Annexure-I — Modified Check List for Reimbursement OM No. 4-18/2005-C&P [Vol. I – Pt. (I)] · Dated 20th February, 2009

CENTRAL GOVERNMENT HEALTH SCHEME

Modified Check List for Reimbursement of Medical Claims

(Please tick (✓) the relevant column)

Sl.	Item	Status
1.	CGHS Token No. and place of issue	............
2.	Validity of CGH Card (For pensioners) & Entitlement — from.......... to.......... | Pvt./Semi Pvt./General	............
3.	Full name of Card Holder (Block Letters)	............
4.	Status (Govt. Servant / Pensioner / Other)	............
5.	The following documents are submitted (Please tick ✓ relevant column):
	(a) Medical 2004 Form	Yes / No
	(b) Photocopy of CGHS card	Yes / No
	(c) No. of Original Bills	............
	(d) Copy of discharge summary	Yes / No
	(e) Copy of referral by Specialist / CMO	Yes / No
	(f) Whether hospital has given breakup for lab investigations	Yes / No
(g)	Original papers lost — following documents submitted:
	I. Photocopies of claim papers	Yes / No
	II. Affidavit on Stamp Paper	Yes / No
(h)	In case of death of card holder — following documents submitted:
	I. Affidavit on Stamp paper by Claimant	Yes / No
	II. No objection from other legal Heirs on Stamp papers	Yes / No
	III. Copy of death certificate	Yes / No

Dated: ............ Signature of CGHS card holder Tel. (O) .......... (R) ..........

Name of the Bank .............. Branch .............. SB A/C No. ............ Branch MICR Code .............. Tel. No. of Bank Branch ..............

e-mail Address: ............................................................................

No. 4-18/2005-C&P [Vol. I – Pt. (I)] — CGHS (P) Division, MoHFW, GoI Page 1 postalrulings.blogspot.com