CONTRIBUTORY HEALTH SERVICE SCHEME

In our endeavor to improve Patients friendly CHSS services, application forms for New CHSS Card, dependent CHSS card, Shifting of zonal dispensary and many other facilities have been simplified. These forms can be downloaded and used.

The photocopies of these forms as well as printed copies downloaded from the web site would be accepted from the applicant.

Kindly ensure for the Compatible Hindi Font before downloading bilingual Word Document


Form Name Description PDF Word
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Renewal of CHSS Card for the year 2011

Renewal of CHSS cards in respect of Parents/Parents-in-law/Dependent relatives and children aged between 18 and 25 years for the year 2011

 NA
Children Registration Above 25 Years

Application for extension of CHSS cards to children whose age is beyond 25 years
CHSS Card
(CHSS–1/260-A)

Application for CHSS card of employee. This form has to be filled out while Initial Registration.
Available in English version, employee has to be filled out this form in Quadruplicate.
CHSS Card (Beneficiaries of deceased employee)
(CHSS–1/260-B)

Application for CHSS card for beneficiaries of deceased employee.
Available in English version, has to be filled in by the Beneficiary of the deceased employee in Quadruplicate.
Addition of Beneficiaries
(CHSS–4/271)

In case of addition of names of beneficiaries use this form. Part I of the form to be filled in by the applicant.
Available in English, to be filled in Single copy.
Deletion of names of beneficiaries
(CHSS–7/281)

Application for deletion of names of beneficiaries. Part I of the form to be filled in by applicant.
Available in English, to be filled in Single copy.
MRD Data Entry Form

This form is used for general information of employees and their beneficiaries.
Single form should be filled for every employee and their beneficiaries.

 NA
Lost Card

Application for issue of new CHSS card in lieu of CHSS cards Lost/Misplaced/Mutilated
This form should be filled in Duplicate.
Revalidation of Child Beneficiary

Application of declaration for revalidation of the CHSS card of Chlidren

 NA
Revalidation of Dependents

Application form for revalidation of the CHSS facility of parents/parents-in-law and other dependents registered under defination "Relative" paying per-capita expenditure.

 NA
Change of Zonal Dispensary
(CHSS–5/282)

In case of change in zonal dispensaries beneficiary should fill this form. Part I of the form to be filled un by applicant.
Available in English, to be filled in Quadruplicate.
Med. 97 A

Form of application for claiming refund of medical expenses incurred in connection with medical attendance/treatment of Central Government servants and their families - FOR TREATMENT IN A HOSPITAL

 NA
Med. 97 B

Form of application for claiming refund of medical expenses incurred in connection with medical attendance/treatment of Central Government servants and their families - FOR MEDICAL ATTENDANCE BY AUTHORISED MEDICAL ATTENDANT

 NA
LES Form - 1

Claim for reimbursement of medical expenses in case of patient has taken treatment as an outpatient. Employee has to fill out separate claim for each patient. Available in English as well as in Hindi version.

NA
LES Form - 3

Claim for reimbursement of medical expenses in case of patient has taken treatment as an inpatient. Available in English version.

NA
CHSS - 6

Claim for reimbursement of Confinement Charges. Available in English version. Employee has to be submitted in duplicate.
Reimbursement on purchase of medicine.
(For Retired Employees)

Application for claiming reimbursement of expenses on purchase of medicine etc. Recommended by CHSS Medical Centers/Doctors. Available in English version.

 NA
Reimbursement on purchase of medicine.
(For Working Employees)

Application for claiming reimbursement of expenses on purchase of medicine etc. Recommended by CHSS Medical Centers/Doctors (Other than LES).

NA
CHSS Registration for Retired Officials
(CHSS - 12)

Application for registration under CHSS-Retired officials. Applicant should fill this form in triplicate and quadraplicate in case of employee is other than BARC employee.

 NA
Ambulance Reimbursement Form

Application for claiming reimbursement of Ambulance Hire Charges

 NA

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BARC HOSPITAL
ANUSHAKTINAGAR, NEAR DEONAR, MUMBAI - 400 094
TEL: 022 - 2559 8000, 2556 3140 FAX: 2550 6944