REIMBURSEMENT CLAIM FORM

(ANNEXURE (A) TO LETTER NO. 494- E/Q VII DT. 24.2.99 amended vide
Railway Board’s letter No.2005/H/6-4/ Policy-I, Dated 01.06.2017)

1. Name of the Railway/ Retired Employee (in BLOCK letters): ………………………………….……………………

2. Designation of the Railway/ Retired Employee (in BLOCK letters) : ……………………………………..…………

3. Office and Station of Employment: ………………………………………………………………………………….

4. Pay/Last Pay of the Railway/ Retired Employee including grade pay: ……………………………………………..

5. Residential address: ………………………………………………………………………………………………….

…………………………..……………………….....................Phone No. …...........................................................

6. Medical I. Card /RELHS No. : ………………………………… and Issuing Authority: …………………….....

7. I. Medical I. Card /RELHS registered at Health Unit/ Hospital. : ………………………………………………
II. (A) Name and age of the Patient : ……………………………………………………Age : ……………….Years
II. (B) Patient’s relationship to the RLy./Retd. Employee: ……………………………………………………………

III. Details of Indoor Treatment at Non Railway Institute:

A. Name of Hospital: ……………………………………………………………………………………………….
B. Date of Admission: ………………………………………………………………………………………………
C. Date of Discharge: ……………………………………………………………………………………………….
D. Diagnosis: ……………………………………………………………………………………………………….
E. Amount of Total Hospital Bill (Attach detailed Bill) : …………………………………………………….
F. Whether Treatment was taken in Emergency: ……………………………………………………………
G. Are You a CSTE Member (Y/N): ………………………………………………………………………………..

IV. Whether subscribing to any Health Insurance Policy or covered under any other Health Scheme. If yes,
have you received any amount from insurance company for the treatment in question. Give details
if any on separate sheet of paper.

V. Total Amount Claimed: …………………………………………………………………………………………….

VI. Details of Bank Account where Reimbursement amount is to be paid.

a. Name of Bank: …………………………………………. b. Account No. : ……………………………………

c. Branch MICR Code: …………………………………… d. IFSC Code: ………………………………………

contd. 2 page
 2

VII. List of enclosures (Please Tick the documents attached and write additional documents)
A. Photocopy of Medical I/Card/RELHS Card.
B. Essentiality-cum- Emergency Certificate by the Non Rly. Hospital.
C. Discharge Summary.
D. Original Bills of Hospital.
E. Original Cash Vouchers of Drugs/Consumables. Implants etc. if relevant.
F. Outer Pouch of Stent, Pacemaker, Implants etc.
G. Any other enclosure _________________________________________
(In case of many enclosures, write number of additional enclosures here and attach a separate sheet
with details)

DECLARATION TO BE SIGNED BY THE RAILWAY EMPLOYEE

I, hereby declare that the statements in this application are true to the best of my knowledge and belief and that the
person for whom medical expenses were incurred is wholly dependent upon me. I am aware that misuse of medical
facilities for misrepresentation of any kind can attract penal action including cancellation of MIC/RELHS Card. I
hereby declare that this is my final claim and I shall not make any claim in future to Railway or any Health scheme in
respect to this treatment episode.

………………………………………………….
Signature of Railway employee/ Claimant

Date ……………………………

Place …………………………..

______________________________________________________________________________

In case the beneficiary has medical insurance policy and intend to make claim for the treatment in question then he/she
may make claim to insurance company first and then submit claim to Railway with documents, bills etc. attested by
insurance company.
 Check List

S.N. Particulars Placed at

S.N.
1 Photo Copy of Medical Identity Card/ RELHS Card duly attested

2 Essentiality-cum-Emergency Certificate (Signed by the Medical Officer

in-charge of the case at the non-Railway Hospital with Name and
Stamp/Seal)
3 Discharge Summary/ Death Summary

4 Original Bills of Hospital (Duly verified & countersigned by treating

Doctor (Authorized Medical Officer). Not by Casualty Doctor)
5 Original Cash Vouchers of Drugs/Consumables, Implants etc. if
relevant.
6 Outer Pouch of Stent, Pacemaker, Implants etc.

7 Any other enclosure----------------------- ( in case of many enclosures,

write number of additional enclosures here and attach a separate
sheet with details)
a-Attested Copy of Pay Slip/ PPO Pension Order

b-Attested Copy of PAN Card

c-ECS/RTGS MANDATE FORM with Cancelled Cheque

d-Detailed item wise break up of all the bills

e-Report of Investigation/ Procedures done during treatment

8 Claim Performa duly filled in all respect

9 Application/Self Statement giving Circumstances under which he/she

took treatment

10 Others, if any
 Essentiality cum Emergency Certificate
Northern Railway
Medical Department

I certify that Shri/Smt./Kumar/Kumari …..…………………………………………

Wife/Son/Daughter/Dependent relative of Shri/Smt……………………………. .

Employed in Indian Railway as ……………………………………………………. has

been under my treatment for...............................................................disease

from………………………………to …………………………………………………at the

………………………………………………………………………………….Hospital and

the treatment as described in the attached Discharge card No….……………….

and attached bills thereon were provided due to an emergency situation,

treatment for which could not have been delayed, I further certify that the

treatment provided was essentially required.

Date: …………………………………………
Signature of the Medical Officer
In charge of the case at the non-Railway Hospital
With Name and Stamp/Seal.

Date: ………….………………………………
Signature of Hospital In-charge or
Authorized signatory with Stamp/Seal
 सभी बिल ों की मद / तारीखनु सार साराोंश
DETAIL OF DATE WISE / ITEM WISE BREAK UP OF ALL THE BILLS OF
(र गी का नाम /Name of patient)………..........................................................................................
क्र. सों. बदनाक बिल सोंख्या दवा बवक्रेता/फमम का नाम मद का बववरण मात्रा कीमत
Sr. No. Date Bill No. Name of Chemist/Firm Description of Item Quantity Price

............................................................... .........................................................................
प्राबिकृत बिबकत्साबिकारी के हस्ताक्षर बिबकत्साबिकारी/अस्पताल के इों िार्म के हस्ताक्षर
Signature of Authorised Medical Officer Signature of the Medical Office / Incharge of
the case of the Hospital