Sl. No. Name of the Hospitals Address 9. Bharti Eye Hospital E-52, Greater Kailash-I, New Delhi. 10. Vision Eye Hospital F-24/136, Sector-7, Rohini, N

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6 Annexure I LIST OF CGHS EMPANELLED HOSPITALS / DIAGNOSTIC CENTRES APPROVED FOR AVAILING FACILITIES OF MEDICAL TREATMENT / DIAGNOSTIC TESTS ON CASHLESS BASIS (as on ) अनल नक-I ग कशलस आध र पर च क त स / र ग न द पर क षण स व ध ओ ल भ उठ ललए अ म ददत स ज ए एस प लबद ध अस पत ल / र ग न द न दर स त ) Sl. No. Name of the Hospitals 1. Gandhi Hospital (A unit of Pawan Gandhi Healthcare Pvt. Ltd.) Address C-50 &51, OM Vihar, Uttam Nagar, New Delhi ID Contact No. gandhi_doc2004@yahoo.c om gnhome.2010@gmail.com Treatment / procedure for which Accredited hospital/centre has been empanelled OR General Medicine, General Surgery, Gynae. & Obs., Orthopaedic (including Joint Replacement), Otorhinolaryngology, Respiratory Medicine, Cardiology, Medical Gastroenterology, Nephrology, Neurology, Neurosurgery, Cardiology, Urology (including dialysis and lithotripsy) Eye, Dental and Diagnostic Dharamshila Hospital & Research Centre Name changed w.e.f , to 2. Dharamshila Narayana Super-Specialty Hospital (A unit of Dharamshila Cancer Foundation and Research entre) 3. Cygnus Orthocare Hospital Dharamshila Marg Vasundhara Enclave, Near New Ashok Nagar Metro Station, Delhi Tripathi@narayanahealth. org 011 Prem.shankar@narayanah , ealth.org Accredited Hem.Pant@narayanahealt h.org C-5/29, Opp. IIT Main Gate, Safdarjung Development Area, New Delhi admin.coh@cygnushospi tals.com w.e.f General Medicine, General Surgery, Nephrology including Dialysis, Neuro Surgery, Neurology, Urology, Gastroenterology, Orthopedic Surgery, Cardiology, Endocrinology, Otorhinolaryngology, Paediatrics, Psychiatry, Respiratory Medicine, Transplant Services (Blood and Bone Marrow Stem Cell), Dental and Diagnostic, Cancer treatment (Chemotherapy Cancer Surgery & Radiotherapy). General Medicine, Gynae & Obs., Orthopedics and joint replacements, General Surgery, Endoscopic/ Laproscopic procedures, Neurology & Neuro Surgery, Gastroenterology, Dental, Urology & Nephrology, Eye, ENT and Diagnostics Endoscopic/ Laparoscopic procedures, Gynecology& Obstetrics, Orthopedic surgery with Joint replacement, General Medicine, General Surgery, Neurology & Neuro Surgery, Urology, Nephrology and (Including Dialysis), Gastroenterology, Pulmonology, Paediatrics and Diagnostics. 4. Jeewan Nursing Home & Hospital 2-B, Pusa Road, Karol Bagh, New Delhi c. 5. Mangalam Medical and Surgical Centre 154/81, Main Bawana Road, Pooth Khurd, Near Sector35, Delhi mangalammscentre@gm 011ail.com sharma.deepak248@gmai l.com General Medicine, General Surgery, Gynecology and Obst, Orthopedic, Eye, ENT, Endoscopic/Laparoscopic Surgery, Gastroenterology, Neurology, Urology, nephrology, Dental and Diagnostics. 6. Delhi Heart Hospital 176, Jagriti Enclave, Bhartendu Harish Chandra Marg, Near Karkardooma Metro Station, Delhi info@delhihearthospital.o rg General Medicine, Respiratory Medicine, Non-Interventional Cardiology 7. Venu Eye Institute & Research Centre 1/31, Sheikh Sarai Institutional Area, Phase-2, New Delhi billing@venueyeinstitute. org / Bharti Eye Foundation 1/3 East Patel Nagar, New Delhi. info@bhartieye.com Accredited w.e.f ee a ca 49 Accredited

7 Sl. No. Name of the Hospitals Address 9. Bharti Eye Hospital E-52, Greater Kailash-I, New Delhi. 10. Vision Eye Hospital F-24/136, Sector-7, Rohini, New Delhi Dr. Kapur s The Healing Touch Eye Center D-8, Vikas Puri, New Delhi ID Contact No. Treatment / procedure for which Accredited hospital/centre has been empanelled OR info@bhartieye.com , Accredited w.e.f nayarvipul@gmail.com , NON12. Eye Health Clinic 13. Visitech Eye Centre ( A unit of Jasola Healthcare LLP) 16. info@eyehealthclin Plot No. 2, Pocket-I, Jasola Vihar, New Delhi c AG-152, Shalimar Bagh, New Delhi info@jaineyehospital.com Leela Dental Clinic B-39, Main Road, Majlis Park, Delhi. info@leeladentalclinic.co m, dklal39@gmail.com All Available Dental Care Facilities Leela Dental Clinic 9, Hakikat Nagar, Gate No.1, GTB Nagar, Kingsway Camp, Delhi-9. info@leeladentalclinic.co m, dklal39@gmail.com All Available Dental Care Facilities Interventional Cardiology & Cardiothoracic & Cardiovascular Surgery, Endoscopic/ Laparoscopic procedures, Gynecology & Obstetrics, Orthopedic Surgery including Joint Replacement, General Medicine, General Surgery, Pulmonology, Neurology & Neurosurgery, Urology & Nephrology (Including Dialysis), Gastroenterology and GI Surgery, Paediatrics, Eye & ENT, Dental, Cancer treatment (Surgery, Chemotherapy) and Diagnostics General Medicine, General Surgery, Gynae. & Obs., Orthopaedic (excluding Joint Replacement), Medical Gastroenterology and Diagnostic. Jain Eye Hospital and Laser 14. Centre 15. E-1, Sector-61, Noida /63, a a. a Kalra Hospital SRCNC Pvt. Ltd. A-4, 5&6 Tulsi Dass Kalra Marg, Kirti Nagar, New Delhi kalrahospital68@gmail.co , m Kalra Hospital, Dwarka (A Unit of Kalra Hospital SRCNC Pvt. Ltd.) 3A, 26-27, Sewak Park Extension, Opp. Metro Pillar No. 761, Dwarka Mor, Uttam Nagar, Delhi kalrahospital68@gmail.co , m General Medicine, General Surgery, Gynae. & Obs., Orthopedics, Paediatrics, Respiratory Medicine, Cardiology (noninterventional), Urology (including Lithotripsy), ENT, Dental and Diagnostics 19. Kosmos Super Speciality Hospital C-60,Anand Vihar (Vikas Marg), Delhi. kosmoshospital@gmail.co m kosmoshospital@yahoo.c om 20. Itek Vision Centre (A unit of Skiffle Healthcare Services Ltd.) B-1A/22, Sector-51, Ground Floor, Noida info@itekvisioncentre.co m Dev Eye Centre (A unit of Skiffle Healthcare Services Ltd.) R-10, Vakil Colony, Sector-12, Pratap Vihar, Ghaziabad info@deveyecentre.com

8 Sl. No. Name of the Hospitals 22. Sanya Diagnostics centre (A unit of Sanya GIC Imaging Pvt. Ltd.) Centre For Sight (A Unit of New Delhi Centre For Sight Ltd. Changed w.e.f Centre For Sight (A Unit of New Delhi Centre For Sight Ltd. Changed w.e.f Centre For Sight (A Unit of New Delhi Centre For Sight Ltd. Changed w.e.f Centre For Sight (A Unit of New Delhi Centre For Sight Ltd. Changed w.e.f Centre For Sight (A Unit of New Delhi Centre For Sight Ltd. Changed w.e.f Centre For Sight (A Unit of New Delhi Centre For Sight Ltd. Changed w.e.f Address ID Contact No. Treatment / procedure for which Accredited hospital/centre has been empanelled OR A-25, Near HDFC BANK Hauz Khas, Delhi info@sanyadiagnosticsdel hi.com X-ray, Mammography, USG, MRI, CT, Bone Densitometry J-12/30, Rajouri Garden, New Delhi , inforajouri@centreforsigh 011t.net / , 3rd Floor, Ring Road Mall, Sector-3, Rohini. 011inforohini@centreforsight /01/02.net /0. B-5/24, Safdarjung Enclave, New Delhi. info@centreforsight.net , , SCO Complex-317, Sector - 29, Gurgaon infogurgaon@centreforsi ght.net /18/ F-19, Preet Vihar, Main Vikas Marg, New Delhi. Abhishek.Kumar@centref , orsight.net Tarun.luthra@centreforsi ght.net 12 A/20, Opp. Bal Bharti Public School, Dwarka. Delhi. 011infodarka@centreforsight /01.net /05 sec@shroffeye.in Accredited w.e.f Shroff Eye Centre A-9, Kailash Colony, New Delhi 30. Kapil Dental Clinic & Implant Center A-1/681, Sector-6, Rohini, Delhi kapildental@drdentiste.co m drkapilsaroha.ortho@gmai l.com All Available Dental Care Facilities 31. Manas Hospital (A Unit of Sharma Medical Centre Pvt. Ltd.) A-93, Sector-34, Gautam Budh Nagar, Noida manashospitalnoida@gm ail.com QCI Recommen ded General Medicine, General Surgery, Gynae. & Obs., Orthopaedic (excluding Joint Replacement), Paediatrics, Nephrology including dialysis, Neurology, ENT, Dental and Diagnostics. Cardiology, Cardiothoracic & Vascular Surgery, General Medicine, General Surgery, Gynae & Obs., Orthopedic surgery including Joint replacement, Urology, Respiratory Medicine, Nephrology (including dialysis, Neurosurgery, Urology, Medical Gastroenterology & Chemotherapy only, and Diagnostics. General Medicine, General Surgery, Gynae & Obs., Orthopedics including joint replacements, Respiratory Medicine, ENT, Medical & Surgical Gastroenterology, Urology excluding Dialysis and Lithotripsy, Eye and dental and Diagnostics Universal Centre of Health Science Bypass Road, dr_shailesh20@yahoo.co Molarband Extension, m Badarpur, New Delhiuchsindia@gmail.com Indus Valley Hospital 232, KH. No.19/1 (112), 135, Laxmi Garden, Tehsil Road, Nagafgarh, New Delhi indusvalleyhospitals@gm ail.com

9 Sl. No Name of the Hospitals Kailash Eye Care (Unit of Kailash Nursing Home) Felix Hospital (Felix Healthcare Pvt. Ltd.), Address 50-51, South Patel Nagar (Near Metro Pillar No.190), New Delhi. ID Contact No , Treatment / procedure for which Accredited hospital/centre has been empanelled OR Accredited Interventional Cardiology & Cardiothoracic Surgery, Laparoscopic/ Endoscopic procedures, Gynecology & Obstetrics, Orthopedic Surgery including Joint Replacement, Pulmonology, Rheumatology,General Medicine, General Surgery, Neurology & Neurosurgery, Urology & Nephrology (Including Dialysis), Gastroenterology and GI Surgery, Vascular & Plastic Surgery, Paediatrics, Eye & ENT, Dental, Cancer treatment (Surgery, Chemotherapy) and Diagnostics. Shop Plot No 4, First Floor, Anand drsmriti@drishtieyecare.c Complex, Pandav Nagar Patparganj, Rd., om Opp. Mother Dairy, Delhi Shop No.1, DDA Market, Bank Enclave, Delhi All available Dental Care Facilities 0120NH-1, Sector137,Expressway, Noida info@felixhospital.com, felixhospitals@gmail.com Drishti Eye Care Centre Smile 4 Sure Dental Clinic S4sdental@gmail.com *****************

10 Annexure II PROCEDURE TO BE FOLLOWED FOR AVAILING FACILITIES OF MEDICAL TREATMENT / DIAGNOSTIC TESTS FROM CGHS RECOGNIZED PRIVATE HOSPITALS / CENTRES ON CASHLESS BASIS ) FOR BENEFICIARIES AVAILING MEDICAL FACILITIES UNDER CGHS I) PROCEDURE FOR OPD CONSULTATION WITH THE SPECIALIST OF CGHS EMPANELLED HOSPITAL i) The CGHS beneficiaries may seek OPD consultation from Specialists at Private hospitals empanelled under CGHS after being referred by any Medical Officer / CMO of CGHS Wellness Centre; ii) The MO/CMO of the CGHS Wellness Centre shall refer the beneficiary for consultation on a computer generated prescription slip; iii) After consultation with the Specialist at empanelled hospital, the beneficiary shall report back to concerned Wellness Centres, where MO/CMO shall endorse on the listed investigation / treatment procedure, if any advised by the Specialist; iv) Thereafter, the beneficiary shall approach the empanelled hospital / centre, for the prescribed investigations. No permission is required from office in such cases; v) The beneficiaries shall have to seek permission from the Office, as per prevailing practice, for unlisted investigation / treatment procedure, if any prescribed by the Specialist; and vi) The medicines prescribed by Specialists shall be supplied by CGHS as per the available generic name at the CGHS Wellness Centre. II) PROCEDURE FOR UNDERGOING SPECIFIC TREATMENT PROCEDURE (LISTED) FROM THE CGHS EMPANELLED HOSPITAL, AFTER THE SPECIFIC TREATMENT PROCEDURE ADVISED BY SPECIALIST OF CENTRAL GOVT./ STATE GOVT. OR A CGHS MEDICAL OFFICER i) Once the Specialist of Central Govt./ State Govt. / CGHS or a CGHS Medical Officer ADVISES any specific treatment procedure (listed), the beneficiary can directly undergo the same procedure from any of the CGHS empanelled hospitals of his / her choice. No permission is required from office in such cases; ii) iii) (Note It is not compulsory to get case referred for treatment to any CGHS recognized hospital); In case of Haemo-Dialysis, the advice of the Specialist of Central Govt./ State Govt. / CGHS or a CGHS Medical Officer for treatment shall be valid for upto six months. Thereafter, ADVICE of the Specialist will have to be obtained; and In case of Radio-therapy / Chemotherapy, the ADVICE of the Specialist of the Central Govt./ State Govt. / CGHS or a CGHS Medical Officer, the ADVICE shall be valid for all the cycles of Radio-therapy / Chemotherapy. The specialist has to specify the specific Radio-therapy procedure.

11 III) PROCEDURE FOR AVAILING POST-OPERATIVE FOLLOW UP TREATMENT RELATING TO NEURO SURGERY, CARDIAC SURGERY, CANCER SURGERY/ CHEMOTHERAPY/ RADIOTHERAPY, KIDNEY TRANSPLANTATION, HIP/KNEE REPLACEMENT SURGERY AND ACCIDENT CASES The BIS beneficiary can avail the facility of Post-operative follow up treatment relating to Neuro Surgery, Cardiac Surgery, Cancer Surgery/ Chemotherapy/ Radiotherapy, Kidney transplantation, Hip/Knee replacement surgery and accident cases, from the same hospital, subject to the following conditions a) The beneficiary shall have to obtain prior permission from BIS for such follow-up treatment, as per prevailing practice, which shall remain valid for 3-6 months at a time and shall be extended if required on the basis of medical record; b) Reimbursement of expenditure for Consultant / treatment including hospitalization, if required/investigations, will be limited to rates as fixed under CGHS; and c) The beneficiary shall collect all the OPD medicines prescribed in connection with the treatment from the CGHS dispensary ) FOR THE BENEFICIARIES AVAILING MEDICAL FACILITIES UNDER CSMA RULES (i.e. the beneficiaries not covered under CGHS) PROCEDURE FOR AVAILING FACILITIES OF SPECIFIC TREATMENT PROCEDURE / DIAGNOSTIC TESTS In case, the Specialist of Central Govt./ State Govt. or an AMA appointed in respect of the concerned beneficiary, ADVISES the beneficiary for a listed specific treatment procedure / test, the beneficiary can undergo the said treatment / test at any of the CGHS empanelled hospitals of his / her choice, after obtaining prior permission from the Competent Authority of BIS, as per prevailing practice IN THE CASE OF EMERGENCY i) The followings ailments shall be treated as case of emergency (the list is illustrative only and not exhaustive depending upon the condition of the patient)- Acute Coronary Syndrome (Coronary Artery By-pass -Graft/Percutaneous Transluminal Coronary Angioplasty) including Myocardial Infarction. Unstable Angina, Ventricular Arrhythmias, Paroxysmal Supra Ventricular Tachycardia, Cardiac Temponade, Acute Left Ventricular Failure/Severs Congestive Cardiac Failure, Accelerated Hypertension, Complete Heart Block and Stroke Adam attack, Acute Aortic dissection. Acute Limb Tschernia, Rupture of Aneurism, Medical and Surgical Shock and Peripheral Circulatory Failure

12 Cerebo-Vascular Attack, Stroke, Sudden Unconsciousness, head injury, Respiratory Failure, Decompressed Lung disease, Cerebro Meningeal Infections, convulsions, Acute Paralysis, Acute Visual loss. Acute Abdomen such as acute appendicitis, acute pancreatitis, acute cholecystitis, acute renal colic, acute intermittent porphyries etc.\ Road Traffic Accidents/with injuries including fall & firing. Acute Poisoning Acute Renal Failure Acute Abdomen in female including acute Obstetrical and Gynecological emergencies. HeatStroke/Heat Exhaustion Burns of all types. ii) The BIS beneficiary shall be allowed treatment on cashless basis on production of the identity documents, listed under the INSTRUCTIONS FOR THE BIS BENEFICIARIES; The empanelled hospital shall not refuse admission or shall not demand for the advance or shall not insist for referral letter from BIS beneficiary. iii)

13 अनल नक-II ग कशलस आध र पर स ज एचएस म न यत त व अ पत ल / कन र स चचककत स / र ग ननद न पर क षण क सव ध ऍ लन क ललए अनस रण क ज न ल क य ) स ज एचएस क तहत चचककत स स व ध क ल उ न न ल ल उ चथ य क ललए I) स ज एचएस पनलबद ध अ पत ल क व शज स i) स ज ए एस ल भ र थ, स ज ए एस स स य न दर क स भ च क त स अचध र / स एमओ प पर मश हत क य द र रफर क ए ज ब द स ज ए एस तहत प लबद ध प र इ ट अस पत ल व ज स ओप ड पर म श ल स त ह ; ii) स ज ए एस स स य न दर च क त स अचध र /स एमओ यटर सत जत पर म श प पर पर म श हत ल भ र थ रफर रग ; iii) यदद प लबद ध अस पत ल व ज छ सल ह दत ह त ल भ र थ स ब चधत स स य न दर वपस ररप टश रग तर थ स ज ए एस मडड ल ऑकफसर/स एमओ द गय स बद ध ज / ईल ज प रक य पष ठ endorse) रग ; iv) इस ब द ल भ र थ न ध शररत (prescribed) ज हत प लबद ध अस पत ल/ न दर स स प श रग ऐस म मल म य शलय स अ म नत ल जर रत ह ह ग ; v) यदद व ज द र ई गर-स बद ध स ख / ज ललख ज त ह त ल भ र थ उस ज ललए ल ग र नत अ स र य शलय स अ मनत ल ह ग ; ए vi) व ज द र ललख गई द ईय स ज ए एस स स य न दर द र उपलब ध ज रर म अ स र द ज ए ग II) कन र य सरक र/र य सरक र क व शज य स ज एचएस चचककत स अचधक र द र द ग सल ह पर स ज एचएस पनलबद ध अ पत ल स सच बद ध व शज पच र त करन क क य II) न दर य सर र/र य सर र/ स ज ए एस व ज य स ज ए एस च क त स अचध र जब क स स बद ध व ज उप र प रक य सल ह दत ह त ल भ र थ अप पस द क स भ प लबद ध अस पत ल स स ध उस उप र प रक य स व ध प र त र स त ह ऐस म मल म य शलय स अ मनत ल आ श य त ह ह ग ; ध य न द क स भ स ज ए एस म न दयत प र त अस पत ल स ईल ज हत स रफर र जर र ह ह) ;

14 हम ड यलललसस म मल म न दर य सर र/र य सर र/ स ज ए एस व ज य ii) स ज ए एस च क त स अचध र सल ह छह मह त ध रहग इस ब द प हम ड यलललसस र हत न दर य सर र/र य सर र/ स ज ए एस व ज य स ज ए एस च क त स अचध र सल ह ल ह ग ; और iii) रडडय र थरप / म र थरप म मल म न दर य सर र/र य सर र/ स ज ए एस व ज य स ज ए एस च क त स अचध र सल ह रडडय र थरप / म र थरप सभ cycles) हत ध ह ग व ज / च क त स अचध र व ज रडडय र थरप / म र थरप प रक य न ददश षट र ह ग III न यर सज र, क र एक सज र, क सर सज र / क म थरप / रर य थरप, गद त य र पण, क ल ह/ट न बदलन क सज र ए दट न स बन न धत म मल म ऑपरशन क ब द ज च क य (प परट फ ल - प) क स व ध त करन क क य ब आईएस ल भ र थ न दयर सजशर, डडशए सजशर, सर सजशर / म र थरप / रडडय र थरप, ग द प रत य र पण, ल ह/ट ट बदल सजशर ए दट शट स बचधत म मल म न म लल खत तत अध उस अस पत ल स ऑपरशन क ब द ज च क य (प परट फ ल - प) क सव ध प र त र स त ह ) ल भ र थ फ ल -अप ईल ज ललए ल ग र नतय अ स र ब आईएस स प श अ म नत ल ह ग, ज क ए ब र म 3-6 म ह ललए ध ह ग और च क त स आध र पर आ श य त स र पर इस बढ य ज एग रर डश ख) पर म श / यदद आ श य ह आ त, अस पत ल म इल ज हत भत रह हत / ज, पर ह ए ख अद यग, स ज ए एस अ तगशत तय दर स म म रहग ए ग) ल भ र थ, ईल ज हत ओप ड द र न ध शररत द इय, स ज ए एस डडस प सर स ह प र त र ग स एस एम ए ननयम क तहत चचककत स स व ध क ल उ न न ल ल उ चथ य क ललए (अथ त स ज एचएस क तहत क र न ह न ल ल उ थ ) व शज पच र क य / र ग ननद न पर क षण क स व ध क ल उ न न क ललए क य यदद न दर य सर र / र य सर र अस पत ल व ज य स बतन दधत ल भ र थ हत न य क त ए एम ए, ल भ र थ स बद ध व ज उप र प रक य / पर क षण हत सल ह दत ह त ल भ र थ, ल ग र नत अ स र, ब आईएस सक षम प र चध र स प श मनत प र त र ब द अप पस द क स भ स ज ए एस प लबद ध अस पत ल स उक त ईल ज / पर क षण र स त ह

15 3. i) आप तक ल न (वमरजस ) पररन थनत म न म लल खत ब म ररय आप तक ल न (इमरज स ) म मल र प म समझ ज एग स व स तत ह र ल उद हरण र थश ह, ज क र ग द पर न भशर रग ) एक यट र र लस ड र म र र आट र ब य-प स-ग र फ ट/परक यटन यस ट र सललयलम ल र र ए तजय ल स ट ), तजसम म य डडशयल इ फ क श लमल ह अतस र थर ए तज, दट र लर एररचर थलमय, प र तक सस मल स प र दट र लर टच डडशय, डडशय टम प ड, एक यटलफ ट दट र लर फललयर/स सश जतस ट डडश फल य र, त ररत ह इपरट, पणश ह टश ब ल और स ट र एडम अट, एक यटओरदट ड इसक स एक यट लल ब ट सरन य, र र ऑफ एन दयररय म, सतजश ल और मडड ल ए पररफरल सक यल श टर फल य र सरब - स लर अट, स ट र, अ बह, लसर ट, रसवपरट र फल य र, डड प रस ड फफड ब म र, सरब र मन तजयल स मण, लस, एक यट पक ष ट त, एक यट व ज ल स एक यट एप डडस इदटस, एक यट पन द अट इदटस, एक यट ल स इलसस ट, एक यट र ल लल, एक यटइटरलमट ट प ररफररस आदद जस अक यट एबड म र ग सड दट श ए / चगर और आग लग स, लग ल ट सदहत ट एक यट प इजन ग एक यट रर ल फललयर ग द म र ) मदहल ओ म एक यटऑबसट रदट ल और ग य ल तज ल आप त तस र थनत म ह टस ट र / ह ट एक ज स सभ प र र बन दसश ii) ब आईएस ल भ चर थशय ललए ददए न द तहत स बद ध पह दस त ज ददख पर ह ब आईएस ल भ चर थशय लस इल ज अ मनत द ज एग iii) स बद ध अस पत ल द खल र स म ह रग य अचग रम र ल म ग ह रग य ब आईएस ल भ र थ स रफरल पत र ललए ज़ र ह दग

16 Annexure-III INSTRUCTIONS FOR THE BIS BENEFICIARTIES BIS beneficiaries are compulsorily required to present the following documents for availing medical facilities from CGHS empanelled hospital/centre on cashless basis I) BIS beneficiaries of Delhi /NCR covered under CGHS i) Prescription Slip issued by the Specialist of the Central Govt./State Govt./or MO/CMO of CGHS (either in original or a self-attested photocopy thereof); ii) Identity Card issued by BIS to the employee/pensioner/family pensioner; and iii) CGHS Token Card issued in the name of the BIS employee/ pensioner/ family pensioner / dependent family member. II) BIS beneficiaries of Delhi /NCR not covered under CGHS i) Permission letter from BIS in respect of the treatment/tests prescribed by the Specialist of the Central Govt./State Govt./or AMA appointed in respect of the concerned beneficiary (either in original or a self-attested photocopy thereof); ii) Identity Card issued by BIS to the employee; and iii) Identity Certificate issued in the name of the BIS employee consisting details of the dependent family members and the details of the AMA, for availing medical facilities under CSMA Rules. 2. For availing the facilities of treatment / procedure / diagnosis, the BIS serving and pensioner beneficiaries, respectively, shall have to fill in and sign Medical Form No. F-1/9 and FORM MRC submit the same in hospital / centre, for making reimbursement by BIS to the empanelled hospital. A copy each of the format of the Medical Form No. F-1/9 and FORM MRC(P), is attached as Annexure - V

17 अनल ग नक - III ब आ एस ल उ चथ य क ललए ननद श 1. स ज ए एस स बद ध अस पत ल / न दर स कशलस चचककत स स व ध त करन क ललए ब आईएस ल भ चर थशय ननम नललख त द त ज अनन य र प स तत र ह ग I) i) स ज एचएस क अ तग त श लमल टदल ल /एनस आर क ब आ एस ल उ थ स ज ए एस एम ओ / स एम ओ / र य सर र / र सर र अस पत ल व ज द र द गई सल ह प वप रसक तस लप) य त मल य स सत य वपत फ ट प ); ii) मश र / प भ ग / परर र प भ ग ब आईएस द र ज र पह पत र; तर थ iii) ब आईएस मश र / प र / परर र प र /आच त परर र सदस य म पर ज र स ज ए एस ट डश II) स ज एचएस क अ तग त श लमल न ह न ल टदल ल / एनस आर क ब आ एस ल उ थ i) न दर य सर र / र य सर र अस पत ल व ज य स बतन दधत ल भ र थ हत न य क त ए एम ए द र ब आईएस ल भ र थ द उप र प रक य य पर क षण सल ह आध र पर ददय गए स बतन दधत उप र/पर क षण हत ब आईएस स अ मनत पत र य त मल य स -सत य वपत फ ट प ); ii) मश र ब आईएस द र ज र पह पत र; तर थ iii) स एसएमए न यम तहत च क त स स व ध ओ ल भ उठ ललए, ब एसआई मश र म पर ज र पह पत र तजसम आच त परर र सदस य व रण और न य क त क ए गए एएमए व रण लमल ह 2. उप र / प रक य / न द पर क षण स व ध ओ ल भ उठ ललए, ब आईएस स रत त ल भ चर थशय ए प ल भ चर थशय म मर कल फ म स. एफ-1/9 ए फ म एम आर स (प ), भर ह ग और ब आईएस द र स बद ध अस पत ल ख प रनतपनतश स ब ध म अस पत ल / र म जम र ह ग मर कल फ म स. एफ-1/9 ए फ म एम आर स (प ) प र र प अनब ध-V म स लग ह

18 Annexure IV CERTAIN TERMS & CONDITIONS FOR INFORMATIONS OF THE BIS BENEFICIARIES The BIS log shall be displayed by the empanelled hospital to enable the BIS beneficiaries to avail medical facilities conveniently as per their requirement. 2. The BIS authorities may visit the hospital / centre any time to check and verify the identity of the beneficiary, facilities & treatment being given, etc. 3. All medicines and medicinal requirements, injections, surgical materials and disposable items required for medical treatment of the beneficiary as per medical norms, shall be supplied by the empanelled hospital/centre. 4 In case, the empanelled hospital/centre does not have the facility to provide such items necessitated from the medical point of view for treatment of the BIS beneficiary within its own resources, the empanelled hospital/centre shall itself arrange to obtain such items from outside medical sources. 5 In case, the empanelled hospital/centre does not have facility to carry out some of the diagnostic tests, necessitated from medical point of view for treatment of the beneficiary, the empanelled hospital/centre shall itself arrange to carry out these tests at other CGHS approved Diagnostic Centres. 6 During In-patient Department (IPD) treatment of BIS beneficiary, the empanelled hospital/centre shall not ask the beneficiary to purchase separately the medicines from outside. The empanelled hospital shall bear the cost at its own as per the package deal rate fixed by the CGHS. 7 The empanelled hospital/centre shall provide the facilities of treatment / diagnostic tests to BIS beneficiaries through the panel of consultants / Doctors / Surgeons / Medical Staff according to the established clinical protocols and prevalent norms in the medical world. 8 The empanelled hospital shall provide inpatient accommodation in accordance with approved entitlement of the BIS beneficiary. 9 The BIS beneficiary shall have to make payment before discharge from empanelled hospital in respect of the services availed which are not admissible under CGHS

19 अन लग नक -IV ब आ एस ल उ चथ य क ललए ननध ररत क छ ननब धन और शत 1. स बद ध अस पत ल द र ब आईएस ल ग द शय ज एग त क ब आईएस ल भ र थ आ श य त स र आस स च क त स स व ध ओ ल भ उठ स 2. उ ब आईएस प र चध र ल भ र थ पह, द ज ल सव ध ओ / उप र, इत य दद सत य प र हत क स भ समय अस पत ल/ र द र र स त ह 3. ल भ चर थशय च क त स य इल ज ललए अपक षक षत सभ च क त स य आ श य त ओ और द ईय, डडस प जबल आइटम ए सतजश ल पद र थश, इ जक आपनतश च क त स म द ड 4. अ स र स बद ध अस पत ल/ न दर द र ह ज एग यदद, स बद ध अस पत ल/ र म अप स स ध म स ब आईएस ल भ र थ ललए च क त स द तषट स आ श य स त ओ प रद र स व ध ह ह, त स बद ध अस पत ल/ र ब ह य च क त स य स र त स स य ह ऐस स त ओ प र त र व य स र थ रग 5. यदद, स बद ध अस पत ल/ र म क स द न पर क षण र स व ध ह ह, ज क ल भ चर थशय इल ज ललए च क त स द तषट स जर र ह, त स बद ध अस पत ल/ र स य अन दय स ज ए एस म न दयत प र त द न र पर इ पर क षण र व य स र थ रग 6. अ तर ग र ग व भ ग आईप ड ) म इल ज द र, स बद ध अस पत ल/ र, ब आईएस ल भ चर थशय ब हर स द ईय खर द ललए ह ह ग स बद ध अस पत ल स ज ए एस द र न यत प ज ड ल दर अ स र ल गत स य ह 7. रग स बद ध अस पत ल/ र, ब आईएस ल भ चर थशय पर म श /ड क टर/सजश /मडड ल स ट फ प ल म ध यम स स र थ वपत द न प र ट ल और च क त स दन य म प र ललत म द ड अ स र उप र / द न पर क षण स व ध ए प रद रग 8. स बद ध अस पत ल ब आईएस ल भ चर थशय उ न ध शररत प त रत अ स र ह इ प ट आ स य स व ध प रद रग 9. ब आईएस ल भ चर थशय स बद ध अस पत ल स डडस जश ह स पहल ल गई ऐस स ओ, ज स ज ए एस अ तगशत अस यश ह, स ब ध म भ गत र ह ग

20 Annexure V / अनल ग नक - V 1. Form F I 9 to be filled in by the serving beneficiaries 2. Form MRC (P) to be filled in by the pensioner beneficiaries

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23 FORM -MRC (P) (For pensioner beneficiaries) BUREAU OF INDIAN STANDARD Medical Reimbursement Claim Form (CGHS) (To be filled by the Principal Card holder/claimant in BLOCK LETTERS) 1. (a) (b) (c) (d) (e) (f) (g) Name of the Principal CGHS Card Holder CGHS Ben ID No. CGHS Wellness Center to which the card is attached Validity of CGHS Card Ward Entitlement - Pvt./Semi-Pvt./General Full Address Mobile telephone No. and address, if any 2. (a) Patient's Name (b) Patient's CGHS Ben ID No. (c) Relationship with the Principal CGHS card holder 3. Category of pensioner beneficiary - please specify (Central Govt. Pensioner/Pensioner of Autonomous/Statutory body/ex-governor/ Former Judge of Supreme Court/ Former Judge of High Court/Freedom Fighter/Legal Heir/Others) 4. Name & address of the hospital/diagnostic center/ Imaging center where treatment is taken or test or done 5. Whether the hospital/diagnostic/imaging center is Empanelled under CGHS Yes/No 6. Treatment for which reimbursement claimed (a) OPD/Test & investigations (b) Indoor Treatment 7. Whether credit facility was availed. If not, Reasons thereof (clarification may be attached) 8. Whether treatment was taken in emergency Yes/No 9. Whether prior permission was taken in emergency Yes/No 10. Whether subscribing to any health/medical insurance scheme, If yes, amount claimed/received 11. Total amount claimed (a) OPD Treatment (b) Indoor Treatment (c) Tests Investigation Yes/No 12. Name of the Bank... Branch MICR Code... SB A/c No.... IFSC Code... DECLARATION I hereby declare that the statements made in the application are true to the best of my knowledge and belief and the person for whom medical expenses were incurred is wholly dependent on me. I am a CGHS beneficiary and the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules. Date... Place... Signature of the Principal CGHS card holder/ Claimant P.P.O. No.

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