Form - C1

Reimbursement for cost of Out-Door Patient (OPD) treatment in

Recognised/Empanelled /Enlisted Hospital Under West Bengal Health Scheme
(As per Order No.127-F(MED)WB, dated 26.11.2021)
(Generated by Employee from Health Portal)

To
The Principal Secretary , School Education Department
5Th Floor, Bikash Bhavan, Salt Lake, Kolkata-700091.
Sir / Madam,
I am submitting a claim of Rs. 2993 (Rupees. Two Thousand Nine Hundred and Ninety Three ) towards
reimbursement for cost of Out-Patient Department (OPD) treatment at recognised / empanelled / enlisted hospital
under West Bengal Health Scheme as per details stated below:

Part-I[General Information]
1. Details of Employee.
Full Name PROBIR KUMAR BISWAS HRMS ID 2009009461
Enrolment ID No. WB/EMP/04/000090691 Claim Application ID E20251027404
Bed Entitlement GENERAL Date of Enrolment 01/12/2010
2. Details of Patient, Treating Hospital and Condonation Requirement, if any.
2.1 Name of Patient PARIMAL BISWAS
Beneficiary ID ADM/WB/82972/5/6
Relationship with Employee FATHER
Name of
2.2 Recognised/Empanelled/Enlisted FORTIS HOSPITALS LIMITED
hospital where treatment is availed.
Code of Hospital 0411040
Class of Entitlement of Hospital Class-1
Address of Hospital 730,ANANDAPUR, KOLKATA-700107
2.3 Requirement of approval of delay NO
Condonation, if any
3.Details of Claimant (Applicable in case of death of employee )
Sl. No. Name of Claimant Relation
3.1
4.Permission Details, If any
Sl. No. Permission sought for Details of permission approval
4.1 For treatment availed in enlisted hospital Memo No. :
outside West Bengal(see clause 14 of -----------------------------------------------------------------
order no.7287, dated 19.09.2008). Date :
-----------------------------------------------------------------
Designation / Authority :
-----------------------------------------------------------------
U.O. No. and date of
Finance Deptt.West Bengal, if any :

Part-II [Details and Expenditure Statement of OPD treatment]

 Form - C1
Reimbursement for cost of Out-Door Patient (OPD) treatment in
Recognised/Empanelled /Enlisted Hospital Under West Bengal Health Scheme
(As per Order No.127-F(MED)WB, dated 26.11.2021)
(Generated by Employee from Health Portal)
5. Details of OPD Treatment
Sl. No. Particulars Details
Category of OPD Claim (Tick mark in As per clause 7(1) of 7287–F, dated : 19-09-2008
appropriate box) [See list of
5.1
diseases/illness mentioned in clause 7
(1) and 7(2)]
5.2 Name and Nature of OPD Disease/ Heart Diseases , Continuous
Illness or follow-up medical
attendance and treatment
5.3 Date of OPD/Follow Up consultation 01/10/2024
6. Expenditure Statement of OPD/Follow Up treatment
Sl No. Name of Component Amount Claimed (Rs.)
6.1 Procedure Charges
Amount Admissible
Sl No. Name of Procedure Procedure Code
(Rs.)
6.2 Consultation Fees 250
6.3 Cost of Pathological and Radiological Investigations
Name of Coded / Non- Code of Amount
Sl No.
Investigation Coded Investigation Admissible (Rs.)
6.4 Cost of Medicines
Period of post consultation From 01/03/2025 To 30/05/202 2743
medicine consumption 5
6.5 Cost of Implant / Prosthesis & Special Device
Name of Implant /
Code of Implant / Amount
Sl No. Prosthesis & Special 0
Prosthesis & Special Device Admissible (Rs.)
Device
6.6 Miscellaneous
Total 2993
No. of vouchers 4

Net Claim:
2993 Two Thousand Nine Hundred and Ninety Three Only

Part-V [Declaration of Employee]

I hereby declare that the statements made in the application for claim are true to the best of my
knowledge and belief. The person, for whom medical expenses are incurred, is a beneficiary of West
Bengal Health Scheme and possessed a valid enrolment certificate at the time treatment. I will be
personally responsible and liable for taking disciplinary action in terms of WBS (CCA) Rules 1971 if the
claim finds false and malafide due to any suppression of facts. I am enclosing the following instrument
to substantiate my claims in sequential manner.

[List of Enclosures]
 Form - C1
Reimbursement for cost of Out-Door Patient (OPD) treatment in
Recognised/Empanelled /Enlisted Hospital Under West Bengal Health Scheme
(As per Order No.127-F(MED)WB, dated 26.11.2021)
(Generated by Employee from Health Portal)
Enclosed or not (Please
Sl. No. Name/Particulars of enclosures to be attached
Tick)
Annexure-I duly signed with proper stamp by Treating
Consultant/Specialist of a Recognised/Empanelled/Enlisted Hospital
1. Yes o No o
or copy of duly signed and stamped Annexure-I (See notes of
annexure-I carefully).
2. Original Money Receipts in chronological dates Yes o No o
3. Copy of OPD prescription Yes o No o
4. Copy of Permission grant if any Yes o No o
5. Original copy of Voucher/ Tax Invoice of Implants purchased Yes o No o
6. Copy of all investigation/ test reports in sequentially. Yes o No o
Essentiality supported with prescription and audiometric report from
treating recognised/empanelled hospital/diagnostic centre
7. Yes o No o
(Applicable only for claiming reimbursement of Prosthesis and
Special Devices).
In case of death of Employee,
a. An affidavit on stamp paper by claimant Yes o No o
8. Yes o No o
b. No objection from other legal heirs on stamp papers Yes o No o
c. Copy of death certificate
9. Any other instruments (Specify) Yes o No o

Date: Signature of the Employee/Claimant:

Name in Block Letters :

Designation :