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    CMRF Form English - Final

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    gudepukumar280
    This document is an application form for treatment assistance from the Chief Minister's Relief Fund. It requests information such as the patient's name, address, age, annual family income, details of illness and treatment received, whether the patient has other sources of financial assistance, and certification from the treating physician. The applicant must declare that neither they nor their family members are government employees and must submit documents like income certificate and hospital discharge summary.

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    Download as PDF, TXT or read online from Scribd

    CMRF Form English - Final

    Uploaded by

    gudepukumar280
    26 views3 pages
    This document is an application form for treatment assistance from the Chief Minister's Relief Fund. It requests information such as the patient's name, address, age, annual family income, details of illness and treatment received, whether the patient has other sources of financial assistance, and certification from the treating physician. The applicant must declare that neither they nor their family members are government employees and must submit documents like income certificate and hospital discharge summary.

    Original Description:

    Cmrf

    Original Title

    CMRF form english _Final

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    This document is an application form for treatment assistance from the Chief Minister's Relief Fund. It requests information such as the patient's name, address, age, annual family income, details of illness and treatment received, whether the patient has other sources of financial assistance, and certification from the treating physician. The applicant must declare that neither they nor their family members are government employees and must submit documents like income certificate and hospital discharge summary.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    26 views3 pages

    CMRF Form English - Final

    Uploaded by

    gudepukumar280
    This document is an application form for treatment assistance from the Chief Minister's Relief Fund. It requests information such as the patient's name, address, age, annual family income, details of illness and treatment received, whether the patient has other sources of financial assistance, and certification from the treating physician. The applicant must declare that neither they nor their family members are government employees and must submit documents like income certificate and hospital discharge summary.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    APPLICATION FORM FOR TREATMENT ASSISTANCE FROM

    CHIEF MINISTER’S RELIEF FUND.

    *Application should be made during the treatment or maximum within three months
    from the date of discharge from the empanelled hospital.

    1. (a) Name of the Patient. :


    (b) Son/Daughter/Wife of :
    2. Age. :
    3. Address
    AT : P.O. :
    Block : Tahasil :
    District : PIN :
    Mobile. No. :
    (Attach the photocopy of the Voter Card/ Aadhar Card)
    4. Name of the applicant, if the application is not :
    made by the patient.
    (Attach the photocopy of the Voter Card/ Aadhar Card)
    5. Applicant’s Relationship with the patient. :
    6. Annual Income of the family. (Attach :
    e- Income Certificate issued by the Tahasildar)
    7. Disease from which suffering :
    8. Name of the Hospital where the treatment :
    is being received.
    (a) Date of Admission :
    (b) Date of Discharge :
    (Attach photocopy of Discharge summary issued by the hospital)

    9. Whether the patient/patient’s spouse/patient’s : Yes No


    parents is/are employee/s (State Govt./Central (Please put (✔) Mark)
    Govt./PSU)

    10. Whether the patient is a BSKY Card /Ration : Yes No


    Card Holder (NFSA/SFSA) (Please put (✔) Mark)

    If yes, Please specify why the cashless :


    treatment benefit was not availed under BSKY
    11. Whether Financial Assistance for the same :
    Purpose has been received from the following.

    (a) BSKY/ CMRF/ PMNRF


    (b) Collector / Municipal Commissioner/ Sub – Collector
    (c) Health Insurance

    If yes, specify the amount and date of sanction:

    12. Checklist (Please tick (✔) the documents submitted)

    Enclose the following documents.


    (a) Photocopy of Discharge Summary
    (b) Final Bills of expenditure in Original
    (c) e-income Certificate
    (d) Photocopy of Voter ID Card/ Aadhar Card
    (e) Photocopy of Organ Donation Permission Letter
    (Mandatory in Organ Transplantation Cases)

    DECLARATION
    I _____________________________________________ son/daughter/wife of
    _______________________________ hereby declare that, the information given above is correct
    and complete in all respects. I also declare that neither I nor my parents nor my spouse are
    employee of the Central / State Government / local body / PSU.

    NB: In case it is detected subsequently that, any fraudulent or misleading information has
    been furnished by me, I shall be liable for legal action as deemed proper by the authorities.

    Place: Signature of the applicant / patient


    Date of submission *Mobile No:
    of application:

    Recommendation of Hon’ble MP/MLA


    TO BE FILLD BY THE TREATING PHYSICIAN OF THE CASE/HOSPITAL ETC.
    WHERE THE PATIET IS RECEIVING/HAS RECEIVED THE TREATMENT
    *******

    1. Patient’s Name :
    2. Name of the Hospital :
    3. Indoor Registration Number and date :
    of admission
    A short note on the present :
    clinical condition of the patient
    4. Important Investigations Done. :
    5. Diagnosis :
    6. Details of treatment
    Indicate date and other details :
    (a) Medicine Management, ICU :
    (b) Surgery :
    (c) Chemotherapy :
    (d) Haemodialysis :
    (e) Others :
    7. Amount of expenditure.
    (a) Cost of important investigations :
    (b) Cost of Surgery :
    (c) Cost of Medicine, etc :
    (d) Hospital Charges :
    8. Whether the patient is assisted under :
    BSKY/Health Insurance. If Yes, the quantum of
    assistance provided/ If no, the reasons
    thereof.

    Recommended By Approved By

    Signature of the Treating Doctors Signature of the Medical Superintendent


    with Official Seal In-charge of the Hospital with Official Seal

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