Form for availing Medical Facilities under CGHS or Fixed Medical Allowance after retirement and format of Undertaking

Form for availing Medical Facilities under CGHS or Fixed Medical Allowance after retirement and format of Undertaking

Form for availing Medical Facilities under CGHS or Fixed Medical Allowance after retirement and format of Undertaking issued vide DoP&PW OM No.F.No.4/34/2017-P&PW(D) dated 31/01/2018

Form for availing Medical Facilities under central Government Health Scheme or Fixed Medical Allowance after retirement.

1. I reside/will be residing at the following address:
Flat/House No/Bldg.

Name
Street/Locality
Village & Post

Office/ Block
City & District
State Pin Code
2. I opt the following facility

(Please tick any one of the following)
i. I will be residing in a CGHS area and would be availing
CGHS facility
       
ii. I will be residing in a CGHS area but would not be
availing CGHS facility, I understand that I will not be
eligible for Fixed Medical Allowance (FMA)
       
iii. I will be residing in non-CGHS area but would be
availing CGHS facility for In-patient Department (IPD) and
Out-patient Department (OPD) treatment. I will not be
eligible for FMA
       
iv. I will he residing in a non-CGHS area but would be
availing CGHS facility for 1PD treatment only by payment of
CGHS contributions. I will also avail FMA for OPD treatment
       
v. I will be residing in a non-CGHS area and would not be
availing CGHS facility for both IPD treatment and OPD
treatment. I will avail FMA.
       
vi, I will avail medical facilities available to
spouse/family members who is an employees/pensioner of
Govemment/PSU/Autonomous Body. I will not avail CGHS
facility and FMA
       
vii. Avail medical facility of previous organization. I
will not avail CGHS facility and FMA
       
This is my one time change in option as provided in the
Rules and it supersedes the earlier option given by me.
I understand that I shall not be able to change this
option again (Strike out this item if not applicable
Name of the retiring employee/pensioner: Mobile No.
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             (Signature of head of office)
                   
                                                       
(Signature of applicant)

form-of-availing-medical-facilities-under-cghs-govempnews
*** 
UNDERTAKING

I ,
_____________________________________________________________ a retired employee of
____________________________________ (Office Address)
___________________________ declare that I am residing at
____________________________________ (Residential Address indicated in
PPO) __________________________________, which area is not covered under CGHS or any
corresponding Health Scheme administered by the Ministry/Department of ,
_____________________________________ (as the case may be). I have also
not obtained and do not wish to obtain a CGHS Card for availing
out-door facilities under CGHS/Corresponding Health Scheme of other
Ministries/Departments from any dispensary situated in an adjoining
area.

Signature_____________________________
Name of pensioner: ____________________
PPO No. _____________________________
Address: _____________________________

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DoP&PW Order dated 31.01.2018 –

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