The list of Private hospitals which have entered into an agreement with MCD / diagnostic centres which have submitted necessary undertaking to extend facilities to municipal beneficiaries are annexed as Annexure A & B respectively.
Further clarifications regarding private recognized hospitals / diagnostic centres are as under: -
1.(a) “Package Rate” shall mean and include lump sum cost of inpatient treatment / day care / diagnostic procedure for which a Municipal beneficiary has been permitted by the competent authority or for treatment under emergency from the time of admission to the time of discharge including (but not limited to) –
(i) Registration charges, (ii) Admission charges, (iii) Accommodation charges
(vii) Doctor / consultant visit charges, (viii) ICU / ICCU charges, (ix) Monitoring charges, (x) Transfusion charges, (xi) Anesthesiacharges,
(xii) Operation theatre charges, (xiii) Procedural charges / surgeon’s fee,(iv) Operation charges, (v) Injection charges, (vi)per-se, does not require admission.same for all categories)Treatment of Cancer in r/o Municipal beneficiaries: - In view of the hardships
3. Dharmshila Cancer Hospital &Research Centre, Dharmshila Marg, Vashndhara Enclave, Delhi Cancer Diagnosis, Chemotherapy,Radiotherapy, Palliative care &general diagnosis purpose.
4. Rajiv Gandhi Cancer & Research Institute, Sector-5, Rohini, Delhi Cancer Diagnosis, Chemotherapy& Radiotherapy.
As the above mentioned hospitals are presently not on the list of CGH empanelled hospitals, these hospitals may not extend credit facilities to pensioners and hence the beneficiaries may have to claim reimbursement at the rates notified in 2001 or actual or whichever is lower, after getting themselves treated at the hospitals.
(xiv) Cost of surgical disposables and all sundries used during hospitalization,
(xv) Cost of medicines, (xvi) Related routine and essential investigations,
(xvii) Physiotherapy charges etc. (xviii) Nursing care and charges for its services.
(b) Cost of Implants is reimbursable in addition to package rates as per CGHSceiling rates for implants or as per actual, in case there is no CGHS prescribedceiling rates.
(c) Treatment charges for newborn baby are separately reimbursable inaddition to delivery charges for mother.
4. Hospitals / diagnostic centers empanelled under MCD shall not charge more thanthe prevailing CGHS Delhi package rates/ rates.
(e) Expenses on toiletries, cosmetics, telephone bills etc, are not reimbursable andare not included in package rates.
5. Package rates envisage duration of indoor treatment as follows:
Upto 12 days: for Specialized (Super Specialities) treatment
Upto 7 days: for other Major Surgeries
Upto 3 days: for Laproscopic surgeries/ normal Deliveries
1 day: for day care / Minor (OPD) surgeries.
No additional charge on account of extended period of stay shall be allowed if thatextension is due to infection on the consequences of surgical procedure or due toany improper procedure and is not justified.
In case, there are no CGHS prescribed rates for any test/procedure, then AIIMS rates are applicable. If there are no AIIMS rates, then reimbursement is to be arrived at by calculating admissible amount item-wise (e.g. room rent, investigations, cost of medicines, procedure charges etc) as per approved rates/ actual, in case of investigations.
3. a) Municipal beneficiaries are entitled to facilities of private, semiprivate or general ward depending on their basic pay / pension as per existing policy.
b) The package rates given in rate list are for semi-private ward.
6. The package rates prescribed are for semi-private ward. If the beneficiary is entitled for general ward there will be a decrease of 10% in the rates; for private ward entitlement there will be an increase of 15%. However, the rates shall be same for investigation irrespective of entitlement, whether the patient is admitted or not and the test,
7. A hospital / diagnostic centre empanelled under MCD, whose rates for treatment procedure / test are lower than the CGHS prescribed rates shall charge as per actual.
8. a) The maximum room rent for different categories would be:
General ward Rs.500/- per day
Semi-Private ward Rs.1000/- per day
Private ward Rs.1500/- per day
Day Care (6-8 Hrs.) Rs.500/-
9. Room rent is applicable only for treatment procedures for which there is noCGHS prescribed package rate.
Room rent will include charges for occupation of Bed, diet for the patient,charges for water and electricity supply, linen charges, nursing charges and routine up keeping,
c) During the treatment in ICCU/ICU, no separate room rent will be admissible.
d) Private ward is defined as a hospital room where single patient is accommodated and which has an attached toilet (lavatory and bath. The room should have furnishings like wardrobe, dressing table, bedside table, sofa set, etc. as well as a bed for attendant. The room has to be air-conditioned.
e) Semi Private ward is defined as a hospital room where two to three patients are accommodated and which has attached toilet facilities and necessary furnishings.
f) General ward is defined as halls that accommodate four to ten patients.
g) Normally the treatment in higher Category of accommodation than the entitled category is not permissible. However, in case of an emergency when the entitled category accommodation is not available, admission in the immediate higher category may be allowed till the entitled category accommodation becomes available. However, if a particular hospital does not have the ward as per entitlement of beneficiary, then the hospital can only bill as per entitlement of the beneficiary even though the treatment was given in higher type of ward. If, on the request of the beneficiary, treatment is provided in a higher category of ward, then the expenditure over and above entitlement will have to be borne by the beneficiary.
6. In case of non-emergencies, the beneficiary shall have the option of availing specific treatment / investigation from any of the empanelled hospitals/ diagnostic centre of his/her choice (provided the hospital / diagnostic centre is empanelled for that treatment procedure/ test), after the specific treatment/investigation has been advised by concerned authority, as detailed earlier.
7. The empanelled hospitals/ diagnostic centers shall honor permission / referral issued by competent authority as detailed above and provide treatment / investigation facilities as specified in the permission/referral.
8. During the In-patient treatment of the Municipal beneficiary, the Hospital will not ask the beneficiary or his attendant to purchase separately the medicines / sundries / equipment or accessories from outside and will provide the treatment within the package rate, fixed by the CGHS which includes the cost of all the items.
9. In case of treatment taken in emergency in any un-empanelled private hospitals, reimbursement shall be considered by competent authority at CGHS prescribed Packages/ rates only.
10. If one or more minor procedures form part of a Major treatment procedure, then package charges would be permissible for Major procedure and only 50% of charges for minor procedure.
11. This will supercede all earlier orders relating to empanelment of Hospitals and diagnostic centers for specialized and General-purpose treatment and investigations for Municipal beneficiaries.
12. faced by beneficiaries under going treatment for cancer (both fresh and old cases) , pending a final decision on the application for empanelment in respect of the following hospitals is continued for a period of six months w.e.f. 2.4.2007 for the facilities / procedures for which they were empanelled under CGHS during 2001. This is in accordance with the MOHFW, GOI OM No.04/JD (Gr.)/CGHSI Delhi/CGHS (P) dated 2.4.2007. The Hospitals are:
Sl.No. Name of the Hospital Empanelled for
1. Indraprashtha Apollo Hospital,Sarita Vihar, Mathura Road, NewDelhi Radiotherapy
2. Batra Hospital & Medical ResearchCentre, 1 Tuglakabad Institutional Area, NewDelhi Chemotherapy & Radiotherapy
13.The revised CGHS package rates in respect to municipal beneficiaries will be effective from the date of issue of this circular
In the existing medical reimbursement facility for serving employees of category C &D, reimbursement is allowed only for 34 specific disease conditions as contained in the circular No.D/756/ADC (H)/87 dated 21.07.1987 as approved vide Corporation Resolution No.29 dated 28.04.1986. The employees under these categories are entitled to monthly medical allowance.
In the revised facility, options can be exercised in a prescribed format (copy annexed as Annexure C by an employee of C & D category whether he / she wishes to join the scheme. In the event of a municipal employee of C & D Category, exercises option to avail this facility, he/she shall be eligible to avail medical reimbursement facility as applicable to officers of A & B category. However, he / she shall have to
1 2. O ther Terms & Conditions..E mployees of C & D category. forego medical allowance effect.payable to him / her. All facilities shall be from prospective The other terms & conditions as contained in the existing medical reimbursement facility for municipal employees & members of the scheme “Medical Facility to Municipal Pensioners/Family Pensioners” shall continue to be the same.
Addl. M.H.O. (Med.)
Copy to: -(Dr. U. C. Tyagi)
1. Secy. to Commissioner, for information of the Commissioner.
2. All Addl. Commissioners.
3. Director Hospital Administration.
4. Municipal Health Officer.
5. Mpl. Secretary.
6. All Dy. Commissioners.
7. All Head of Deptts.
8. All Addl. Dy. Commissioners/Asstt. Commissioners.
9. All Addl. M.H.Os/Dy.MHOs/CAMOs/DHOs.
10. All Medical Superintendents of Major Hospitals.
11. All RMS of Colony Hospital and Polyclinics.
12. All DCAs/ACA’s through ACA/F&G.
13. MO I/c of PHCs/Dispensaries.
14. Guard File/Office copy.
Copy forwarded for favour of information to: -
1. Hon’ble Mayor
2. Hon’ble Deputy Mayor.
3. Hon’ble Chairman, Standing Committee.
4. Hon’ble Leader of House.
5. Hon’ble Leader of Opposition.
6. Hon’ble Chairman, MRPH Committee.
List of recognized private hospitals for MCD beneficiaries
1. Escorts Heart Institute & Research Centre Ltd., Okhla Road, New Delhi Specialised Cardiological services including cardio-thoracic surgery and diagnostic purposes (laboratory, MRI, CT scan, USG, ColourDoppler, X-ray).
2. Jeewan Mala Hospital Pvt. Ltd., New Rohtak Road, New Delhi-5 General and specialised purpose for Laproscopic surgery, Lithotripsy, TURP, IOL and joint replacement.
3. Jeewan Nursing Home and Hospital, 2-B, Pusa Road, New Delhi. General purpose
4. Kalra Hospital, A-5&6, Kirti Nagar, Main Najafgarh Road, New Delhi General and specialised purpose for Cardiological investigation, cardio-thoracic surgery, Haemodialysis, Lithotripsy, TURP, Laproscopi surgery, IOL implant and Joint replacement.
5. Kukreja Hospital & Heart Centre, C- 1, Vishal Enclave, Rajouri Garden, New Delhi General & specialized purpose - Laproscopic and endoscopic surgery. 6. M.G.S. Hospital, Rohtak Road, West Punjabi Bagh, New Delhi For all specialities.
7. Metro Heart Institute, Sector – 12, Noida Cardiology, CTVS, & respiratory purposes.
8. Metro Multi Specialty Hospital, Sector-11, Noida General purpose.
9. Park Hospital, 12, Chowkandi, Outer Ring Road, West Delhi (Near Keshavpur Depot) New Delhi General purpose.
10. Prakash Hospital, T-12, 12-A, 12-B,Sector-33, Noida. General and specialised purpose for Laproscopic surgery, Lithotripsy, TURP, IOL, Joint replacement
11. Surya Hospital, 383/11C, East Azad Nagar, New Delhi-51 General and specialised purposes forLaproscopic surgery.
12. Vinayak Hospital, NH-1, Sector-27,Atta, Noida General and specialised purpose for Laproscopic surgery, IOL and Joint replacement
13. Yashoda Hospital and Research Centre, III-M, Nehru Nagar, & H-1, Kaushambi, Ghaziabad General and Specialised purpose for laparoscopic surgery, IOL implant and joint replacement. Diagnostic services in laboratory medicine and imaging (Mammography, USG/Colour Doppler).
14. Kailash Hospital & Research Centre Ltd., H-33, Sector 27, NOIDA 201301. General and specialised services including cardiology (invasive & non invasive) services, cardiothracic surgery and cardiac surgery and diagnostic services)
15. Delhi Heart & Lung Institute, 3MM– II, Panchkuian Road, New Delhi –110 055Cardiology & Cardiothoracic Vascular Surgery.
16. R.L.K.C Hospital & Heart Institute (A unit of R. L. Khera Charitable Trust) Pandav Nagar, Naraina Road, Near Shadipur Depot, New Delhi Cardiology & Cardiothoracic Vascular Surgery.
17. National Heart Institute, 49,Community Centre, East of Kailash,New Delhi Cardiology & Cardiovascular Surgery
18. Ridge Heart Centre, Sunder Lal JainHospital, Ashok Vihar -3, Delhi – 52 Cardiology & Cardiothoracic Vascular Surgery.
19. Sri Balaji Action Medical Institute, A-4, Paschim Vihar, DelhiGeneral & specialized purpose.
20. Narinder Mohan Hospital & Heart Centre, Mohan Nagar, Ghaziabad- 201007 For Cardiology, Cardiothrocic surgery, medicines, surgery, Obs. & Gynae, Paediatric, Ophthalmology, Nephrology, Skin & VD, Neuro psychiatry , pulmunology, Gastro enterology, urology, neurology, neuro surgery, plastic surgery, ENT, Dental, Orthopaedic , oncology, memology.
21. Metro Hospital & Heart Institute, 14, Ring Road, Lajpat Nagar, NewDelhi Cardiology & Cardiovascular Surgery.
22. Shri Ram Singh Hospital and Heart Institute, B 25- 26&26A, East Krishna Nagar, New Delhi 51. General Purpose including Laparoscopic Surgery & Lithotripsy.
23. Tirath Ram Shah Charitable Hospital, Rajpur Road, Delhi –54.General purpose & Diagnostic
24. Jaipur Golden Hospital, Sec 2, Rohini, Delhi 85Cardiology & Cardiothoracic surgery.
25. Saroj Hospital and Heart Institute Instt.Area, Madhuban Chowk, Rohini, Delhi 85 General and Specialized, Cardiology & Cardiothoracic Surgery.
26. RG Stone Urological Research Institute, East of Kailash, New Delhi-65. Lithotripsy, endourology, laproscopic surgery and holmiology laser surgery.
27. Fortis Hospital B-22, Sector 62,Noida 201301 UP Cardiology, Cardiothoracic surgery, Joint replacement (TKR, THR only and renal transplantation).
28. Metro Hospital & Cancer Institute, 21, Community Centre, Preet Vihar,Delhi. Cardiac, Cancer & general purpose.
29. Sumitra Hospital, A 119 A Sector 35 Noida. General purpose and specialised purpose (Neurosurgery, orthopaedics including arthroscopic surgery and joint replacement endoscopic and laproecopic surgery, Gastroenterology & SI surgery, paediattrics and paediatrics surgery, ENT and ophthalmology.
30 Dr. Pattanik laser Eye Institute, C-2, Lajpat Nagar, New Delhi-110024 Cataract/ Glaucoma, Retinal Medical & Vitreoretinal surgery, Strabismus, Occuloplasty and Adnexa and other specialised treatment.
31. Shree Jeewan Hospital, 67/1 New Rohtak Road, New Delhi Glaucoma and Strabismus.
32. Mohan Eye Institute, 11B Ganga Ram Hospital Marg, Rajinder Nagar, New Delhi-110060 Ophthalmology.
33. Chaudhary Eye Centre and Laser Vision, 4802 Bharat Ram Road, 24, Darya Ganj, New Delhi-110087. Ophthalmology.
34. ICARE Eye Hospital & Post Graduate Institute, E-3A, Sector 26 Noida. Cataract / Glaucoma, Retinal- medical/ vitreoretinal surgery, strabismus, Occuloplasty and Adnexa and other specialised treatment.
35. Venue Eye Institute & Research Centre, 1/31, Sekh Sarai, Institutional Area, Phase-II, New Delhi –110017 Ophthalmology.
Name of the Hospital Empanelled for
A. List of Private Recognized Diagnostic Centers for municipal beneficiaries
Sl.No. Name of the Diagnostic Centre Empanelled for
1. Chetna’s Pathlab, M-26, Basement, Chitranjan Park, New Delhi Laboratory services
2. City X ray and scan clinic (P) Ltd., Tilak Nagar, New Delhi Laboratory services, CT scan, USG/Colour Doppler, MRI, Bone Densitometry, ECG, TMT, X-ray and mammography.
3. City X ray and scan clinic (P) Ltd., Vikas Puri, New Delhi Laboratory services, CT scan, mammography, USG/Colour Doppler and X-Ray.
4. Delhi Heart Hospital, 176, Jagriti Enclave, Vikas Marg Extn., Delhi Laboratory services and Cardiological investigation (colour Doppler, echo cardiography, TMT, Holter and PFT).
5. Delhi Institute for FunctionalImaging, K-16, South Ex., Part –I,New Delhi Diagnostic centre for nuclear medicine
6. Delhi MRI and CT scan Centre, Aashlok Hospital, 25-A, Block AB, Community Center, Safdarjang Enclave, New Delhi CT scan and Ultrsonography only.
7. Delhi MRI Scan Centre, M-2, Hauz Khas, New Delhi MRI, X-ray, Bone Densitometry, USG / Colour Doppler.
8. Dr. A Lal Chandani PathologyLaboratories, J-36, Lajpat Nagar-II, New Delhi Laboratory services
9. Dr. Anand Imaging & Neurological Research Centre, G-14, Preet Vihar, Vikas Marg, Delhi – 92 Imaging services including MRI, CT scan, Ultrsonography / Colour Doppler, X ray and mammography. .
10. Dr. Handa X-ray & Imaging Centre, B-87, Defence Colony, New Delhi USG services only.
11 Dr. M.L Aggarwal X-Ray & Ultrasound Clinic, A-1/150, Safdarjang Enclave, New Delhi. X-ray, Ultrasonography and colour Doppler imaging services
12. Dr. Mittal Diagnostic centre, Madhuban Chowk, Main Outer Ring Road, 611/C-8, Sector-VIII, Rohini, Delhi Laboratory services, USG/Colour Doppler and X-ray.
13.. Dr. P. Bhasin Path Labs (P) Ltd., S-13, Greater Kailash, Part-I, New Delhi Diagnostic procedures in Laboratory services
14. Dr. S.S. Doda's Ultrasound Centre, 23-B, Pusa Road, New Delhi, Delhi CT, Mammography, USG/Colour Doppler, Xray.
15. Dr. Savita Jain's Arun Imaging Centre, D-29, Vivek Vihar, Delhi Diagnostic centre for USG / colour Doppler, Echo mammography, Bone densitometry, XRay, ECG, TMT and Holter
16. Final Diagnosis Centre, C-1/2, Sector-31, Noida. Laboratory services, Ultrasonography and Mammography.
17. First Dwarka Lab, 185, Sector-6, Pocket-I, Dwarka, New Delhi Laboratory services
18. Focus Imaging and Research Centre, C-10, Green Park Extn., New Delhi USG / Colour Doppler, CT scan, Mammography, Bone densitometry and X-ray
19. Focus Imaging and Research Centre, 47/1-2, Yusuf Sarai Market, Aurobindo Marg, New Delhi Diagnostic services in MRI
20. Ganesh Diagnostic and Imaging Centre Pvt. Ltd., Pocket-A-1, Plot No.109, Sector-8, Rohini, New Delhi Laboratory services and Imaging- MRI, CT scan, USG/Colour Doppler and X-ray.
21 GMR Institute of Imaging Research, A-13, Green Park Main, Aurbindo Marg, New Delhi MRI, CT scan, USG / Colour Doppler, X-ray, Bone densitometry and Mammography.
22 Goyal MRI and Diagnostic Centre, B-1/12, Safdarjung Enclave, New Delhi Laboratory services and imaging services in MRI and USG/ Colour Doppler.
23. Green Park Diagnostics, (1st Floor), G-43, Green Park, Main Market, New Delhi Laboratory services
24. India IVF Centre and Research Institute, 17-A, Lajpat Nagar-IV, New Delhi Diagnostic centre for USG / colour Doppler, ECG, TMT and Holter.
25. Janta X-ray and Clinical Lab, WZ-4, Raja Garden, DelhiLaboratory services and imaging viz CT scan,mammography, USG/ Colour Doppler.
26. JDAR Pathology Lab, 2/6, ShantiNiketan, New Delhi Clinical pathology and Clinical Biochemistry.
27. Krystal Scan and DiagnosticCentre, 1, Paschimi Enclave,Rohtak Road, Peeragarhi Crossing,New Delhi.Laboratory services, MRI, CT scan, USG and X-ray.
28. Life Line Laboratory, H-11, Green Park Extention, New Delhi Laboratory services
29. M/S Janta Diagnostic Centre, 12/404, Sunder Vihar, Paschim Vihar, New Delhi Laboratory services, CT, mammography, USG/Colour Doppler, ECG, ECHO
30. Mahajan Imaging Centre, K-18, Hauz Khas Enclave, New Delhi MRI, CT scan, USG/Colour Doppler, mammography, X-ray and Bone Densitometry.
31. Mahajan Nuclear Medicine and Bone Densitometry (Sir Ganga Ram Hospital), Delhi Diagnostic Imaging Services (Bone densitometry and nuclear medicine)
32 Modern Diagnostic & Research Center, 363/4, New Railway Road, Gurgaon Laboratory services, CT scan, mammography, colour Doppler / USG, X-ray and Bone densitometry
33 National CT Scan & DiagnosticCentre, 17, NWA, Club Road,Punjabi Bagh, New Delhi Laboratory services, USG, Bone densitometry,X-ray and CT scan.
34 NMC Imaging Centre (VIMHANS), 1, Institutional Area, Nehru Nagar, New Delhi Laboratory services, MRI, CT scan and X-ray
35 Noble Diagnostic Centre, WZ-409- C, Janak Park, Opp. DDU Hospital,Hari Nagar, New DelhiX-ray and Ultrasonography.
36. Organ Imaging Research Centre,A-23, Green Park, New Delhi MRI, CT scan, X-ray and Bone densitometry.
37. Saral Advanced Diagnostic Pvt. Ltd., E-1073, Saraswati Vihar, Pitam Pura, Delhi Laboratory services, USG / colour Doppler,mammography, CT scan, X-Ray, Bone Densitometry and Nuclear Medicine. services are not recommended.
38. South Delhi Ultrasound & X-Ray Clinic, A-44, Hauz Khas, New Delhi.Ultrasound /Colour Doppler, OPG andMammography
39. Star Imaging and Path Lab, 4B/4,Tilak Nagar, New Delhi Laboratory services, CT scan, Ultrasonography/ colour Doppler, X-ray and Bone densitometry.
40. Sun Imaging Centre, 15,Hargovind Enclave, Vikas Marg Extn., Delhi MRI, CT scan, USG/ Colour Doppler and Bone densitometry
41. Suvidha Diagnostic Center, C-105,Mandwali, Patpar Ganj Society Complex, Opp. I.P. Extn. Delhi. Laboratory services, X-ray and USG/Colour Doppler.
42. The Clinical Laboratory, E-13/9,Vasant Vihar, New Delhi Laboratory services
43. Vasant Vision Ultrasound with Colour Doppler & X-Ray Clinic,F-9/4,Vasant Vihar,NewDelhi Ultrsonography and X- ray.
44 Dr. Lal Path. Lab. (P) Ltd., Eskay Home, 54, Hanuman Road, NewDelhi Laboratories investigations.
45. Millenium Bone Densitometry and Osteoporosis Research Centre, Pusa Road,(Near Tel. Exchange), NewDelhi –05. Bone Densitometry
46 Dr Garg Labs (P) Ltd., A73, Laxmi Nagar, Vikas Marg, NewDelhi 92 All Laboratory investigations exceptHistopathology
47. Dr. Khannas Path care Pvt.Ltd. A-43, Hauz Khas, New Delhi Laboratory (Clinical Pathology, Biochemistry and microbiology)
48 Focus Imaging & Research Centre, IHBAS Complex Dilshad Garden, Delhi Diagnostic Centre (MRI).
49. Nanda Diagnostic Centre, ED- 9A Madhuban Chowk, Pitampura, Delhi. Laboratory (Clinical Pathology and Biochemistry/ Doppler, X-Ray Bone Densitometry).
50 Dr. S.B. Gandhi Diagnostic Centre,A2/152 Janakpuri, New Delhi-110058 Diagnostic services (Laboratory, X-Ray, CT Scan, USG, Color Doppler, MRI).
51 The Apollo Clinic (Licensee Bharti Medicare (P) Ltd.), C 70, Major Sudesh Kumar Marg, Opp. Madhav Park, Near Main Market, Rajouri Garden, New Delhi -110027 Diagnostic services (Laboratory, USG / Colour Doppler, X-Ray, TMT, FFT, ECG and Echo). (AERB approval for X-Ray is not available.)MRI
(To be submitted in triplicate)
Municipal Corpopration of Delhi
Option form (for Group C & D employees)
I_________________________________W/o/S/o/D/o Sh./Smt.__________________ shall not claim medical allowance as payable to me under the rules and will avail the medical reimbursement facility as is applicable to Group A & B category employees/ shall continue to draw medical allowance as is applicable to C & D category and shall not claim any reimbursement of expenditure incurred on treatment of self or dependent family members except those contained in the circular No.756/ADC (H)/87 dated 21.07.1987.
The details are as under: -
1. Name of the employees:
2. Designation :
3. Pay scale :
4.GPF No. :
5. Deptt. Where working :
6. Present Address :
7. Permanent Address :(Strike out which is not applicable)
Signature of the employee with date
Signature of D.D.O. With seal
incumbent. Necessary entry will be made in the service book & ECR. Second copy to be submitted with concerned ACA and third copy will remain with the incumbent. The one copy of the option form shall be attached in service book / personal file of the
In triplicate (Hospital copy/Pensioners copy/office copy) MUNICIPAL CORPORATION OF DELHI (HEALTH DEPARTMENT) S.No. Dated:
(For beneficiaries under the scheme “Medical Facilities to Municipal Pensioners and Family pensioners and their dependents” for cashless transaction / Credit facility in private recognized hospitals)
I, Dr._________________________________, Designation_____________________, am fully authorized to refer the patients to private recognized hospitals under the scheme “Medical Facilities to Municipal Pensioners and family pensioners and their dependents” for cashless transaction (Credit facility).
I am referring Mr/Mrs._________________________________, age / Sex __________to ____________________________ Hospital for necessary treatment as detailed below: -
1.Name of Pensioner/family Pensioner :
2.Medical I. Card No.: _____________ PPO No._________________
3.Relation of the patient with Card Holder :
4. Brief History and provisional diagnosis :
5. Referred for (Purpose) :
The above patient may be extended cashless facility / credit facility as per our agreement. All charges should be as per prevailing CGHS Delhi Rates. Bills raised are to be submitted with office of Addl.Municipal Health Officer (Medical), Municipal Corporation of Delhi, Room No.50-51, Town Hall, Delhi-06.
Signature with seal