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2017-04-21T11:06:22+05:30
2017-04-21T11:06:22+05:30
2017-04-21T11:06:22+05:30
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U N IVERSITY OF ALLAHABAD
ATLAHABAD UNTWRSITY CONTRIBUTORY HEATTH SCHEME
CHECKLIST FOR REIMBI.JRSEMENT OF MEDICAT CTAIMS
l2.J.4.5.
Full name of Diary Holder (Block Letters)Status (Employee/Pensioner/Other)AUCHS DiaryNo.Validity of AUCHS Card (For pensioners) &Entitlement
from ............ toPvt./Semi/General
Yes/lrlo.YesA.{o.YesA[o.
YesA{o.YesA{o.YesA{o.YesA{o.Yes/Irio.
YesA.{oYesA.lo.YesA{o.
Signature of AUCHS card HolderDesignation :Tel. No. (O)(R)e-mail Address:
The following self attested documents are submitted
(Please tick ( { ) the relevant column)
Medical Reimbursement claimPhotocopy of AUCHS CardPhotocopy of Health CardEssentiality Certificate duly signed byNo. of Original BillsWhether original bills/vouchershave been verifiedCopy of discharge summaryCopy of Referral letterWhether the hospital has given breakupFor lab investigationsIf Original papers have been lost theFollowing documents are submitted[. Photocopies of claim papersil. Affidavit on Stamp Paper (Value <100/-In case of death of card holder the followinedocuments are submitted.I. Affidavit containing byClaimant No objection from other legalIfeirs on Stamp papersil. Copy of death certificate
Dated:
Name of Bank IFSC Code
(a)(b)(c)(d)(e)(f)(e)(l1)(i)
(ii )
SB. A/C No.
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