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

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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.


                                
                                                       
             (Signature of head of office)
                   
                                                       
(Signature of applicant)

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


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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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