MRC Form 2004

Medical

15 Mar 2026

Medical 2004 Form — Reimbursement of Medical Claims

Central Government Health Scheme · CGHS Beneficiaries

CENTRAL GOVERNMENT HEALTH SCHEME

Medical 2004 Form for Reimbursement of Medical Claims of CGHS Beneficiaries

(To be filled by the claimant)

Sl.	Field	Entry / Details
1.	CGHS Token No. and Place of issue	: ............
2.	Validity of CGHS Token Card & entitlement	: from .......... to .......... Pvt. / Semi Pvt. / General
3.	Full name of the card holder (Block Letters)	: ............................................
4.	Full address	: ............................................ ............................................
5.	Telephone no.	: (O) .............. (R) ..............
6.	E-mail address if any	: ............................................
7.	Name of the Bank & Branch MICR Code & Tel. of Bank	: Bank: ........... Branch: ........... SB A/C: ........... MICR: ............
8.	Name of the patient & relationship with card holder	: ............................................
9.	Status (tick ✓): Govt. Servant / Pensioner / Autonomous body employee / MP / Ex-MP / Ex-Governor / Former Judge SC or HC / Freedom Fighter / Legal Heir / Others
10.	Basic Pay / Basic Pension	: Rs. ............
11.	Name of Hospital with Address: (a) OPD treatment & investigations (b) Indoor Treatment	: ............................................
12.	Date of admission .......... / Date of discharge .......... (Indoor Treatment only)
13.	Total amount Claimed: (a) OPD Treatment (b) Indoor Treatment	: Rs. ............ : Rs. ............
14.	Details of Referral	: ............................................
15.	Details of Medical advance if any	: ............................................

DECLARATION I hereby declare that the statements made in the application are true to the best of my knowledge and belief and the person for whom medical expenses were incurred is wholly dependant on me. I am a CGHS beneficiary and the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules. Dated: ............ Signature of CGHS card holder

Note: Misuse of CGHS facilities is a criminal offence. Suitable action including cancellation of CGH card shall be taken in case of willful suppression of facts or submission of false statements. Suitable disciplinary action shall be taken in case of serving employees.

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

Medical 2004 Form — Reimbursement of Medical Claims

Central Government Health Scheme · CGHS Beneficiaries

INFORMATION a) Kindly write correct postal address in block letters. b) Obtain Break up of Investigations from the hospital (details and rates of individual tests and the exact number of Sugar tests, X-ray films, etc.,) as the reimbursable amount is calculated as per approved rates only. c) Draft against column (I) of check list — in case of loss of Original Papers. d) Draft against column (I) of check list — in case of Death of Card holder.

No. 4-18/2005-C&P [Vol. I – Pt. (I)] — CGHS (P) Division, MoHFW, GoI Page 2 postalrulings.blogspot.com