Index card

 

Date of Superanuation____________________

 

Govt. of NCT of Delhi

Health & Family Welfare Deptt.

Delhi Govt. Health Scheme

 

1.  Name & Designation of Government Employee______________________________

     (In full & Block Letters)_________________________________________________

 

2.  Department/Office in which employee______________________________________

 

3.  Residential Address ___________________________________________________

                                                ________________________________________________

                                                ________________________________________________

 

4.  Nearest Delhi Govt. Dispensary/Hospital ____________________________________

                                                                        ____________________________________

 

5.  Deatails of Family Members ______________________________________________

 

“Family” includes only wife (or Husband), children or Step Children, dependant, parents, minor Brother and Sisters, Widowed and Widowed Sisters and nor other relations are entitled.

 

S.No.

Name

Date of Birth

Relationship

 

 

 

Self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERFORMA FOR OPTION

 

I, _____________________________________, hereby opt the Scheme for providing medical facility to the employees/pensioner of Delhi Government w.e.f_____________

 

I do not opt the Scheme as my wife/husband is a member of C.G.H.S.  She/He will avail medical facilities under C.G.H.S. and he/she will get reimbursement of Medical treatment in respect of family for special treatment.

 

My wife/husband is employed/not employed in Govt.Deptt. At_______________

She/He will not get the reimbursement of spacial treatment from her/his employer.

 

            The contribution @ Rs.___p.m. May be deducted from my salary for the month of ___ _ Onwards.

 

D......................                                                                                               Signature .................................

                                                                                                                        Name........................................

                                                                                                                        Designation..............................

                                                                                                                        Branch/Deptt.............................

                                                                                                                                    .......................................

                                                                                                                                    .......................................

 

 

List of Enclosures

 

1.Two Unattested Passport size Photographs (self).

 

2.Attested copy of Ration Card/Election Card/Residential proof.

 

3.Affidavit regarding dependency of parents, if so. The  monthly income of your parents from any source, should also be mentioned in the affidavit. It be also mentioned in the affidavit that your parents are getting any Medical Allowance/ Facility from anywhere or not.

 

4.A Declaration signed by the Officer/Official on a plain paper stating that :-

 

(i) The Officer/Official is a regular employee of this office.

 

(ii)That a sum of Rs.....  is being deducted from his/her salary per month.

 

(iii) That the Officer/Official is applying first time for this  medial Card.

 

(iv) That the Officer/ Officer's  spouse is working or not, if working than submit a certificate from the office of your spouse that he/she is not claiming any Medical Allowance/ Facility from his/ her Department.

 

5. Copy of Pay slip of Last month.