Attested by Gr-A officer of that Departmen.

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2 Medical reimbursement Principal Resident Commissioner, Govt. of West Bengal Medical reimbursement Sanction Medical Claim reimbursement [Sl. No. 13(i) of Form-E] i) Affidavit on Stamp Papers to be signed by Notary / Executive Magistrate. ii) No Objection on Stamp Papers from other legal heirs. iii) Death Certificate of Form-E] Affidavit on Stamp Papers. General Diary Attested by Gr-A officer of that Departmen. [Sl. No. 13(h) Pension Sanctioning Authority (PSA) PPO No. PPO No. Temporary Family Permit Permit PPO No WBHS 300/ Notification No F (Med) dt. 19/08/2011 of Finance Department Audit Branch, Medical Cell ( 2

3 IAS WBCS(Exe) Rs.50,000 Medical reimbursement bill sanction Secretary, P&AR Department Rs.50,000 Medical Claim Sanction Divisional Commissioner division IAS WBCS (Exe) Officer Rs.50,000 Medical reimbursement bill sanction Circular No. 158-Secy. P&AR / 2011 Dt. 1 st September, 2011 P&AR Department, IAS Cell, Writer s Building, Kolkata -1 WBHS,08 non-empanelled pvt. hospital / nursing home nursing home WBHS Approved Rates X 80% WBHS Approved Rates X 60% Actual Cost Approved Rate Finance(A) Department, Medical Cell Memo No F (Med) Dt. 16/10/2012 non-empanelled Generic medicine Clause-7 (1) (X), WBHS, 2008) Memo No F (Med) dt. 05/10/2009 ( 3

4 (Audit) Department] Head of office / PSA Intimation [Memo No F (Med) dt. 3/12/2013 of Finance [Memo No F (Med) dt. 3/12/2013 of Finance (Audit) Department] Head of Account Salary Head 12-Medical Reimbursement Under the WBHS, 2008 Head of Account Head of Account 2071-Pension and other Retirement Benefits NP Medical Reimbursement under the West Bengal Health Scheme, 2008 under the Demand No. 18, NP Indoor Outdoor 1. Indoor treatment Three months from the date of discharge. 2. Outdoor treatment Three months from the date of each O.P.D. consultation. (Memo No F (Med) Dt. 05/04/2011, Finance Department, Audit Branch, Medical Cell). WBHS, 08 Medicine Medicine Patient reimbursement Date of purchase of medicines Memo No F (Med) Dt. 8 th April, 2013, Finance Department, Audit Branch Empanelled Hospital Medicine Prescribe Claim reimbursement Patient Medicine Prescribe reimbursement Date of purchase of medicines in such case Medical Cell] [Memo No F (Med) dt. 05/04/2011 of Finance Department, Audit Branch, ( 4

5 Sanctioning Authority Max. Admissible amount Sanctioning Authority Max. Admissible amount Name of the Govt. employee / pensioner with identification number Name of the patient Name of recognized the hospital under the Health Scheme with code no. Name of non-recognized hospital under the Health Scheme with address and bed capacity Name of disease Period of treatment Package code for surgical procedure Head of Account of WBHS, 2008 allotment Memo no F(Y) dt. 12 th December, 2013 Finance Department, Audit Branch Medical Reimbursement / Advances 31 st March, 2014 allotment Medical Insurance Policy Medical Insurance Policy WBHS, 08 reimbursement Insurance Company Medical Claim Insurance Company reimbursement certificate issue Cadre Controlling Authority / Head of Office medical claim vouchers / cash-memos Cadre Controlling Authority / Head of Office WBHS, 08 Reimbursement from sanctioning authority as per WBHS, 08 = Amount admissible as per WBHS, 08 approved rate Amount reimbursed by the insurance company Rs Insurance Company Voucher Rs Rs Rs.32500)= Rs.7500 Head of Office Rs Insurance Company Rs WBHS, 08 Rs Rs.32500) = Rs.5500 ( 5

6 Medical Insurance Policy WBHS Memo No F Dt. 11/05/2009 WBHS, 08 Medical Insurance Company WBHS Medical Insurance Policy WBHS, 08 Memo No F (Med) Dt. 27/07/2012 WBHS, 08 Clause-15 [Clause-16 of 796-F(Med) dt. 31/01/2011] Sanctioning Authority Form-E TR-7 Bypass Surgery, Implantation of Pacemaker, Coronary Angioplasty with Stenting, Kidney transplantation Sanction Sanctioning Authority estimated cost Sanctioning Authority Utilization Certificate adjust TR Form WBHS, 08 Medical reimbursement medical advance T.R. Form No. 68 :- Bill for Medical Charges Reimbursement T.R. Form No. 68A :- Bill for Advance ( 6

7 unsettled unsettled Memo no. 797-F (Med) Dt. 31/01/2011 of Finance Department, Audit Branch, Medical Cell unsettled bill payment Caluse-17 of Temporary Family Permit Temporary Family Permit PPO No. Temporary Family Permit WBHS, 08 case settle Medical Cell, Finance Department discharge [Clause-18 of Memo No. 797-F dt. 31/01/2011] Posting office Health Scheme enrolment Posting office PSA Pension Sanctioning Authority Posting office PSA WBHS enrolment Memo No F (Med) Dt. 22/11/2010 Finance Department, Audit Branch, Medical Cell Department Department Department DM Office WBHS enrolment Posting option Directorate office Form declaration PSA enrolmen He / she has not enrolled his / her name under the Pension Sanctioning Authority or in any other office Enrolment Certificate (Form-II) Finance Department Memo No F Dt. 11/05/2009 Para-4 Claim Settle Sanctioning Authority WBHS Clause-13 ( 7

8 Pension Sanctioning Authority WBHS, 08 enrolment WBHS,08 Sanctioning Authority Memo No F (Med) Dt. 28/09/2012 Finance Audit Department, Medical Cell Form-VII Format PSA PSA Form enrolment WBHS enrolment date Identity Cards orders Form Medical Advance Reimbursement Settled Form WBHS, 08 PSA enrolment Form Form PSA WBHS enrolment Health Scheme claim PSA claim PSA medical claim settle PSA Proforma of Form-VII Form-VII Prayer for change of sanctioning authority in connection with medical facilities under the West Bengal Health Scheme, 2008 (Government pensioner / family pensioner) (Vide F.D. Memo No F (Med) dated 28/09/2012 read with F.D. Memo No F (Med) dated 22/11/2010) To The (Pension Sanctioning Authority) Dear Sir, In terms of F.D. Memo No F (Med) dated 28/09/2012 read with F.D. Memo No F (Med) dated 22/11/2010, I would like to prefer my medical advance / reimbursement bills under W.B.H.S from the (Name of office). I do hereby declare that no claim under WBHS, 2008 will be submitted to you after change of sanctioning authority. I further declare that I will abide by the terms and conditions under the West Bengal Health Scheme, Enclosures:- Signature of the Applicant P.P.O. No. (1) Copy of certificate of enrollment in Form-II (If any) (2) Copy of W.B.H.S Identity Card / Temporary Family Permit in Form-VI (If any) ( 8

9 Memo No F Dt. 11/05/2009 Finance Department, Audit Branch, Medical Cell WBHS, 08 Sl. No. Form required for Govt. employee Form required for Govt. pensioner 1 A I Application for enrolment 2 B II Certificate of enrolment 3 C III Application for settlement of claims for reimbursement 4 (a) D 1 IV 1 OPD - essentiality certificate cum statement of expenditure certificate by treating specialist and counter signed by administrative officer / medical superintendent of the empanelled / recognized hospital 4 (b) D 2 IV 2 Indoor / Day care and related OPD - essentiality certificate cum statement of expenditure certified by treating specialist and counter signed by administrative officer / medical superintendent of the empanelled / recognized hospital 4 (c) D 3 IV 3 Non-recognized Pvt. Hospital - essentiality certificate cum statement of expenditure certified by treating specialist and counter signed by administrative officer / medical superintendent of the empanelled / recognized hospital 5 E V Checklist for medical claims / sanction of advance 6 F VI Temporary Family Permit 7 NIL VII Prayer for change of sanctioning authority in connection with medical facilities under the WBHS, 08 WBHS Category Category Category of Employee / Pensioner I II III Basic Pay (Band Pay including Grade Pay) / Basic Pension Above Rs.27000/- p.m. / Rs.13500/- p.m. Rs.18000/- p.m. and above but below Rs.27000/- / Rs.9000 Rs p.m. Below Rs p.m. / Rs.9000 p.m. Type of accommodation Private ward Semi-private ward General ward Colour of WBHS identity card Yellow Pink White major procedure minor procedure WBHS major procedure minor procedure major procedure minor procedure approved rate ( 9

10 West Bengal Health Scheme authority permission Notification No F (Med) Dt. 10/05/2013 Finance Department, Audit Branch, Medical Cell WBHS, 08 WBHS authority- permission WBHS Digital Hearing Aid West Bengal Health Scheme Authority permission Notification No F (Med) Dt. 10/05/2013 Finance Department Audit Branch Medical Cell Digital Hearing Aid West Bengal Health Scheme Authority permission Digital Hearing Aid Audiometry Report WBHS Code No ,000 Digital Hearing Aid OPD Including Multiple Myeloma OPD B-Thalassemia, Hepatitis C Carcinoma adjust [Memo No F (Med) dt. 6 th September 2013 of Finance Department, Audit Branch] WBHS, (link) WB Health Scheme, 2008 ( 10