13-~1AR-2012 12: 11 From: ICAR HQ NEWDELHI IN 0091+11+23387293 To: 25841282

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INDIAN COUNCIL OF AGRICULTURAL RESEARCHKRISH[ BHA WAN: NEW DELHI

F. No. 21-36/2007-CDN Dated the 12lhMarch, 2012

Circular

Ministry of Health & Family Welfare, Deptt, Of Health & Family WelfareGovernment of India, New Delhi has issued the O.M. No. S11012/3/2011-CGHS(P) dated 29.12.2011 regarding - Issue of Individual Plastic Cards to COBSbeneficiaries. The above mentioned O.M. is being uploaded on the ICAR Web-Sirewww.ical'.org.in for information and further guidance for ICAR Hqrs.only,

M---(J.N. Bhugat)

Under Secretary (GAC)

DISTRIBU'I'ION :-

1.

~4.5.

Sr.PPS to DG. [CAR(PPS to Secretary, ICAR/PS to FA (DARE).Shri Hans Raj, ISO, (DIPA) KAB-I for putting in the ICAR Web-Site.All officers/sections at ICAR Krishi Bhawan/KAB - I & Il.Secy. (Staff Side), I-USC, reAR, KAB-IIGuard file/Spare copies (10)

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IGovernment of lndin

Ministry or Honlth & Fnmlly Wclflll'cDepnr trnen t of Health & Family Welfare

Nlrman Bhuwnn, Mnulana Aznd RoadNew Delhi 110 108•••••••••••••

No. S 11012/3/2011- COl-IS (P) Dated: the 29th December, 20]1

Sub: Issue of Individual Plastic Clll'ds to CGHSbeneficiaries - rcgardtng

The undersigned Is directed to Invite reference to this Ministry's O.M No, Mise"6024/2007/CGHS (HQl/CGHS(P) dated 30111 December, 2009 wherein guidelines onIssue of Individual Plastic cards to each CellS beneficiary (serving and rettred) wereisslled. In order to further streamline the issue of COilS Plastic Cards, the gutdeltuesore revised as follows.-

NEW' PROQEDURE FOR ISSUE OF CaHS CARDS !NDELHI 8( NCR

(A) SERVING EMPLOYEES

1. CGliS Cards shall be Issued only to the eligible Central Govemment employeesand such class of persons as may be decided by the Government whose placeof residence Is situated wtthm the coverage area of COBS.

2. Requtsitfon for CGHS Cards shall be prepared In duplicate In Form 'A', Onecopy to be forwarded to Addltlonal Director (HQl. CCIiS, New Delhi and theother to be retained with the Department where the applicant is currentlyemployed (hereinafter referred to as 'sponsortng authority/Mtntstry/Department') for record,

3. The requisition shall be sponsored by an officer In charge of administration notbelow the rank of Under Secretary,

4. Requisitions (or CCIiS Cards shall be accompanted by two copies of recent 3x5ern. size tndtvtdual photographs of all family members of the governmentemployee, one set of which shall be pasted on the application form and shall beattested by a Gazetted Officer In charge of admtntstrauon. Another set ofphotcgrapns shall be Signed 011 the back by the concerned beneflciary andenclosed with U1C appllcatlon form for onward submlselon to the Offlce ofAddtttonal DIrector (I"IQ),CGliS. New Delhi.

5. Requisitions shall be sent along with two copies of the challan as in Form 'C'duly filled in, to tile Addtttonal Director (HQ), CGHS, New Delhi.

6, The Office of Additional DIrector (HQ), New Delhi shall process the requisitionforme and get the cards prepared tn t.he prescribed format which shall then bedelivered to the concerned sponsoring authortnes as per the laid downprocedure.

Contd .. ,,!l/-

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7. CGHS Cards will be delivered only lo the person authorlsed by the sponsoringauthority after obtalnlng an acknowledgement In Farm 'D',

8_The sponsoring authortty shall ensure that the gOVl:mment employee. forwhose (arnlly members the COl-IS Cards are made out. gives a. proper receipt. ontnJdng deltvery of cardts) by putUng his/her" signature,

9. On the OCCUITence of death, COHS cards Issued la a government. employee.shall be withdrawn and deposited by the Administration of l1ls/her Departmentwith Addlttonal Director (HQ), COBS. New Delh! for cancellation .

.1O./n case of change In entitlement for COHS facilities, the Government. employeeshall enclose t.he COBS carcllsl with the application for tasutrig new cardfs]with the revised entttlement.

11,/n case of muulauon, the mutilated CCHS Card shall be enclosed with theappltcauon along with the chullnn In token of payment of the prescribedcharges Ior Issuing a new card.

12.CCHS Cardts) may be Issued to employees of (;j,utOI101nO\.lS bodles (If COBSIaclllty ls allowed to such body) under' the Administrative Mlulstrtes ofOovernment of India. In accordance with the procedure prescribed above,Offlcers of £1 rank equivalent 01" corresponding to Under Secretary In suchautonomous bodies though not enjoying Secretariat status shall be therequrstuorung authority a .nd certifying autnority In respect of such employees.

13, CGHS Cardfs) for employees of autonoruous bodies attached la the Ministrieswill be issued only If the employee Is residing within the CGHS covered areas.

14:.Dupltcate cards may be Issued on payment of prescribed fee with the details ofthe lost / misplaced cards, For Issue of duplicate cards. the same procedureshall be followed by the concerned employee and hts /Irer epcnsortngauthorlt.y /Department/Office,

Ifi.Thc employees should be encouraged to submit their applications onltne byusing the COIiS portal. After onllne submission of the appllcatlon form theyshould take a print out of the same and submit the hard copy duly signed andphotographs afflxed therecn, to the sponsoring authority for processing andonward submission to the Office of Addttional Director (HQ). COHS for Issuingthe cards. Detailed Instrucuons for onllne submission of appllcauons are atAPPENDIX,

16.The plastic cards Issued by CGBS shall be valid for a period of five years fromthe date of issue, The validity period shall also be indicated on the card.

(B) fENSIONEgS

1. COHS cardta) will be Isaued to the eligible pensioners and his/her dependentfamily members whose place of residence is sttuated in the CGHS coveredareas, However. COliS cnrd(s) can also be Iesued to the pensioners whose placeof residence Is outside the COBS covered areas but they have opted for theCGHS membership.

2. TIle Pensioners have the liberty to enrol themselves with any COBS WellnessCentre I Dispensary of hIs/her choice all over the country irrespective ofhis/her place of realdence.

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3. The retlrtng employee can submit his/her application. form fOJ' PensionerseGI-IS card, in Form '13' duly Illled up with the prescribed details to hll'/herDepartment/Office for processing and sponsortng his/her CGHS membershipto the Office of Addltlonal Director (HQ), CGHS [01' Issuing COI'IS cardts}.

4. Requtsluons (or Penstoners' CCHS Cardls) shall be accompanied by two copiesof recent 3x5 cm, slze Individual photographs of all family members of theretlrlru; employee. one set of which shall be pasted on the appllca lion form andshall be attested by a Gazetted Officer In charge of admlntstrauon. Another setof photographs shall be Signed on the back by the concerned beneflclary andenclosed with the application Iorrn for onward submission to the Offlce ofAddttlonal Director (JiQ). CGllS, New Delht,

5. Retiring employees have the. option to apply [or pensioner card along withpension papers or at least sIX weeks prior 1.0 superannuation. The employeecan authortse hls/hl'!r Department to deduct the requisite COliS contribution[01' his/her pensioner's CGHS card from his/her retirement dues and forwardhis/her appllcation to CGI-IS [or rnnklng of car-Is cardlsl. He may also have theoption to submit: a Demand Draft of the requisite amount for the CCHSmembership wlth his/her application,

6, The Departrnentz Offlce of the retiring employee shall process hls Zherappltcntton alongside hts /ner pension papers on prtority basis and sponsorhis/her application to CaBS for Issuing of CaHS cardts).

7. TIH~ sponsoring authority snall observe the same procedure as for a servingemployee 101' geltlng hta/her CCHS card(s) prepared and delivered to therething employee during his service period Itself preferably on the day ofretirement.

8. The sponsoring Departrnent zOfflce and the Offlce of AddlUonnl Director (HQ).COBS shall ensure that the duly prepared Pensioner CGHS Cardla] orepresented to the retiring employee on the dote of his/her retirement Itselfalongwlth hIs/her opp and other retirement benefits,

9, Penetoners CUll also apply [01' the CCJ-lS membersntp after his/her retirementfrom service. He can opt for the COBS membership even If he resides outsidethe CGHS coverage area. He can also select the COBS Wellneas Centre of hischoice anywhere In the country for obtaining the medical Iaclltues under theScheme.

10, TI1e Pensioners can apply for the CONS cards In the prescribed Form 'B', Theapplrcatton form shall be accompanied by two copies of recent 3x5 cm. sizeindividual photographs of aJI famtly members of the pensioner, one set ofwhlchshall be pasted on the application form and shall be attested by a GazettedOfficer, Another set of photographs shall be signed on the back by t.heconcerned beneflctary and enclosed With the applJcaUon form, The appllcauonalongwtth tilt: requisite CCHS contributton as per the prescribed rate should beeubmitted to the Ofllce of Additional Director (HQ), CGHS. New Delhi.

Contd .... 4/-

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] L'The Office of Additlorml Director (HQ). New Delhi shall pror-ess the appltcatlonforms and get the cards prepared In the prescrtbed format which shall then besent by the. t-1.cgisl.ered post / speed post. /collrler at CCHS cost Ior delivery 1:0the concerned pensioner at his recorded address in the Application form.

J 2.The pensioner should also be Informed through telephone. SMS, emall or byletter about the making of CGHS cards and Its despatch parttculnrs to ensurethat It Is delivered to the correct person. Acknowledgement. of receipt should beobtained from him and kept for record In the ofllce of Addluonal Director.CGBS.

13. CGllS shall Issue the plastic card with a valldtty pertod fOI" which the penslonercard has been applied for with the requtslte contribution. Cards Issued for lifelime valldtty agamst payment of lO years contribution. shall Indicate thevalidity of the card for the life time ..

14. The plaauc cards already Issued with printed valldtty of 1:0 pensionerbcnellctartes, who had paid CGHS contrtbutton fOI" 'Rest of Llfe' would be takenas valld for use for 'Rest of Life'. However. such CGBS beneftcianes have theoption to obtain new plastic cards after five years. If they choose to do so, orUII entitled for CGHS beneflts. whichever Is earlier,

NEW PRQCIDURE fOR ISSUE OF CGHS CARPS IN OTHER CITIltS

The above procedure can also be followed In all other cities 'mul.aI:L<;-mu.tandis' With sultahle rnodtflcatlons. The Card making process would be centralleedIn the office of the AD/.]D, COBS In charge of the city,

mSTRUCTION~ REGABINDQ SUBMISSIQN Of RltQUISItIONS FOR ISSUE AN.QCOIkECTIQlY OF CGI:JS CAlWS

1. Requfaluons fOI" issue of COBS Cardts) should be sent to Addttlonal DIrector(HQ) CGHS. New Delhi. They should also be duly dlartsed In theAdministrative SecUon of the concerned MInistry / Department.

2. It would be the responstbllfty of the Mlnlstry/Department /Autonomous bodiesconcerned to scrutinise the appllcauons carefully before these are sent to theCOBS. 1'11e sponsoring authority concerned should also scrutinise the CGHSCards collected from the COBS (JiQ) before delivery of the same to theapplicant, so as to ensure that each CGJ-IS Cardls) is In order and contatntngall partlculara/Informauon required to be included in the CONS Cardls). In thecase of any error being noticed. the fact should be brought to the notice of theAddltiona.l Director (I"IQ) CGBS, New Delhi tmmedtately, The COBS Cnrdts)should not be delivered to the applicant unul the error is rectified. Allapplications should be thoroughly scrutmtsed by the Mmistrtes etc .. forensuring the correctness of the details Iurnlshed In the requisitions and tilebona fides of the applicant.

3. The Mlnlstry/O1l1ce concerned should nominate a representative, who willdeliver the requtstttona to the Office of Additional Director (HQ) COBS. NewDelhi and collect the CONS Card(s) etc. therefrom, His/her name anddesignation, alorigwtth Identity Card Number should be Indicated on the

Contd .... 5/-

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Chnllan slip In Form 'C', I-lis/her specimen ~Ignat ures on tile Challnn slip wlllalso be duly attested by the Adrntnlstrauon Section of the Mlrustry/Offlceconcerned,

4. The rubber stamp Indicating the name a nd designation of the sponsoringautnortty should IJ(;!afflxed below h18/ her signature on the appltcatlon form.and hls/her telephone number should ;l180 be Indicated to enable the Offlce ofAddttlonal Director {HQ)CGlIS, New DeJhl la contact the officer concerned overthe telephone: or otherwise, In NISC' of any doubt.

5, Each Mlntstry /Offlce shall. from tll'ne to time, nominate an officer to sponsorthe requisitions to be forwarded to the OCOceof Additional Director (HQ)CGHS,New Delhi. The name, designation and telephone no, of the sponaortng officerso appointed by the Mlnl stryy Offlce concerned shall be Inttrnated to the Officeof Addltlonal Director (HQ)CGHS, New Delhi as find when f:l change takes place.

B. It shall be the responstbtltty of the sponsoring all thorlly /Mmtatry/Departmenr/Offlce to ensure that the monthly CGBS contribution atthe prescribed rate Is regularly deducted from the salary bill of the CGliSbeneflclary and remitted to the Government account to keep his/her CGHSmembership alive and valid as COHS Is a contributory scheme.

7. It shall also be the responstblllty of the tndtvldual Central Government.employee 1.0whom the COHS membership has been granted by issuing COBScardts), to deposit nta/Iier monthly COBS ccntrtbutron at. the prescribed ratethrough his/her regular salary bill to keep his/her COHS membership aliveand valtd.

8. It shall be the responslbllHy of the COL-IS beneficiary la criaure that the CGHScardfs) Issued to him and his/her family members are not misused In anycircumstances or by any unauthorised person.

LQSS / MUTMTION Ql CGRS CO!\RP§

1. The holder of the CoHS card is personally responsible fOJ" Its safe cuetody.

2, In case of lose of a COHS card or a temporary Index card. It shall be IncumbentOn the card holder to report the loss Immediately to the Office of the AdditionalDirector (HQ). New Delhi and also to the Ministry or Office which apunsored therequtsttton for the issue of the CGHS curd,

3. On receipt of a report from the card holder about the loss of tile COBS card,the Ministry / Office concerned shall send a Report to U1e Offlce of theAdditional Director (Hg), CGI-IS, and New Delhi giving full details 01' thecircumstances leadJng to the loss of CGBS card.

4. In case the lost CGHS card is subsequently found, the Offlce of AdditionalDirector. CGIiS shall be informed and In case El duplicate one has been tssuedin tile meantime. the original CONS card shall be returned to the Office ofAddttional Director. COHS for cancellation.

Contd" .. 6/-

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5. A penalty of Rs. 50 911i)11be Imposed on the person concerned for the loss orth!.~COHS card, The penalty once deposited will not be refunded even If theCGI-IS card Is subsequently retrieved.

6, The loss 01 eGI'IS card shall be recorded by the Ministry / Office c.ol1cernt'rlin the remarks column against tlre relevant entry In the Register of' CGHScards matntalned by them in U1eprescribed Form 'E'.

7. The Mlnlatry or Health and F'lli111.1y Welfare may In special circumstances andfor the reasons 10 be recorded in writing, waive the penalty eharges for theloss of a COl'IS CUTd In any part.lcutar case,

8. Besides the recovery of penalty charges. a Government employee who falls togive a satlsfactory explanatlon 1'0JoU1C loss of CGHS cnrdls) Issued to him /her, would be liable to dlsctpltnary action,

9. In the case of the loss, mutilation of CGHS card. a temporary card will beIssued only after the penalty charges Ior such loss or rnuulatton. as the casemay be, have been deposited by the concerned employee.

10. Penalty for Mutllatlon of the CGI-IS care! before the period of expiry is Rs 50/-

MISCELLANID2!!§1. CGHS card Issued by the Directorate General of Central Oovernment Hcn.IU1

Scheme (CCHS) Is not transferable.

2. Misuse of CGl'IS card wlll entafl penal consequences and In the Case ofGcvernment employees, dtsclpllnary action can also be taken,

3. On the expiry of the period of validity of a COHS card, the holder of the CGHScard shall surrender It Immediately to the MInistry/Office concerned and applyfor renewal or the COBS cardfs). If necesaary.

4. The holder of a CONS cardls) will surrender it. to the sponsoring authority whenthe CGHS card ts no longer required by htm on account of his transfer orshifting 01' residence to a non-CQliS covered area.

5, Each Ministry / Office sponsoring requlsttions for CGBS cards stlu,Umamtatn aregister In Form 'E' to record the details of COHS cards issued as per therecommendation of the Mlnlatry / Office, This register shall be submitted to theDirectorate Genera] of COHS if and when required for scrutlny.

$, The Mintstry of Health and Family Welfare may tssue any further tnstrucuone,as may be considered necessary to supplement the CGBS Guidelines andInstructions.

Conl.d .... 7/-

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The new procedure as laid down in this Office Memorandum shall be effectiveIrorn th~ 16"' day of .January, 2012 and it supersedes all pn~V10Ll!;m at.ru ctrorrs IssuedIrorn time (0 time on the uubject.

Encl: As above

(V,P, SinghlDeputy Secretary to the Oov~rnment of In.diu

'tol: 2306 1831To1 All Min iatriea / Department:>, Government of India2 Director, CGHS) Nirman Bhawan, New DCUli3 All Additional Directors /Joinl Directors of COHS cities outside Delhi4 All Pay & Accounts Officers under CGHS5 Additional Director (Hqrs] J Additional Director (SZI /

Additional Drrector (NZ) / Additional Director (CZ) / Additional Director (ll:Zl.CGHS. New Delhi

6 JD (Gr )/,JD(R&J-l), CGHS Del.lli, Hospital Empanelment Cell, Nirman Bhawun7 COHS Dcak-IjDesk-lIjCGHS-I/CGHS"ll, Dte.GHS, Nirman Bhnwnn. New Delhi8 l!stt..l/ Estt.lJ/ Estt.Jll/ EstUV Sections, Ministry of Health & Family Welfare9 Admn.r / Adrnri.H Sections of Dte.OHS10 Rajya Sabha / Lok Sabha Secretariat11 Registr-ar, Supreme Court of India / Punjab & Haryuna High Court; Chundigarh12 U,P.S..C.13 Finance Division14 Deputy Secretary (Civil Service News), Department of Administrative Reforms L~

Public Grievances, 511. Floor, Sardar Parel Bhawan, New Delhi.15. MS of Hospitals now being empanelled under CGRS, Delhi16 PPS to Secretary ([:l&FWj / Secretary (AYUSH) / Secretary (HHl / Secretary

(AIDS Control], Ministry of Health & Family Welfare17 PPS to DOHS / SS&FA / SS & MD, NRHM J AS (H) / AS & DO (COl'IS)18 Swamy Publishers (P) Ltd., P. 13.No. 2468, R. A. Puram, Chennai 600028.19 Shri Umracmal Purohit, Secretary, Stuff Side, J3-C, Fercasheh Road, New

Delh i20 All Staff Side Members of National Council (JCMI (as per list attached)21 Office of the Comptroller & Auditor General of India, 10 Bahadur Shah Zafar

Marg, New Delhi22 All Officca / Sections / Desks in the Ministry23 Se Technical Director, NIC, MOHFW, Nirman Bhawan, New Delhi with the

request to upland on the web site of the CGHS.24 Office Order folder25 Guard f<'ile

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APPENDIX

PROCIWURE FQ1~ ONL[NE FILLlCiG OF 1)6TA FOR t:/EW CGIIS CARDS / ANI)~rK CAIU)I'I FOB. !~XISTlNG eMU} HQLmms.

A, New CGHS Cards

A Provision is there to fill up dutu on npplicntlou form uvnilnule online Serving employee/pensioner interested to fill lip duta themselves may log 011 to the silt! 1\1I[l:(lcullUl.i&.ill, He /Sill! shall click 011 the lurk 'Appl~' for Plustlc Curds'. Two options would open. He I she shnllclick on the option 'New clllplnyccs / pensioners who III'C not CGHS beneficlnrles 11Pili)'for Plustlc Cards' and fill up data in the online Dnta base. After the data is Iilled in andsubmiued the: system shall generate a Token number to identify the; application fOr'11'I generated.A print command is required for laking a print out and photos of self and other family membersshllll be affixed 011 the form

In CII~e of serving employees, the applictulon lurrn i~to be verified nnd authenticated by his/hcr Ministry /depunmcnr z Organization and forwarded to CGHS office.

AI CGHS office the tillhl [lllcd up hy applicam would be retrieved by using the token numberand liner verificuuon of Dntu bused on the authenticarion given by department III case ofserving employees and after verification of supporting documents in case of pensioners,[orwurd the data online to the ngency preparing the Plnst le Cards. Photos arc scanned andimages uploaded A printout ~hllll be issued nfter allotment of CGHS Wcllncss centre, whichshall be valid till the Plastic Card i~received.

B, Plastic Cards for cr:J-tS bcnoflciurics already enrolled und have not applied for'Plastic Cards

Serving employee/ pensioner interested 10 fill up data themselves may IoU on to the sitehttp://cehs.nic.ln " He / she shal] click on the link ·Apllly for Plustic Curds': Two optionswould open, They shull click the option - 'Existing CGllS beneflclarles who huve notapplled fur Plastic Cards' and enter COI'IS Dispensary/ CGHS Card number I /Cuiegory orsimply enter the Ben ID and enter. A form 9hnll appear with Ben ID, A print out of some Ilhllllbe filled up and photos are affixed. The form shall be nuthenticated by Ministry /Depurunent /Orgunizntion concerned line! forwarded 10 CGHS. TIle data is forwarded online to the agencyfor preparing Plnsric curds.

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FORM -6APPLI<;ATION fOR C(iHS CA(lp.f,Qk.SfRyING eMPLoyees OF CfNTRAL.CjOYfRNMENI

1. N:)me of the Applicant: _.

Departmental c:J Servlccs I I

{ PionsI' -nck Dep;Htm(!nt~llf you arc posted in till:' Ministry or Health 81Fllmily Wcl(~rcj DGHS 1 CGliS }{ PIOll!iOlkk Servlcc~ Ir you belona to anv ~pc:cjflc organized scrvtcc }

3. NiHIl!:! of ()epOlrtmcl1t

4- Name or I:he Service . _( In case of Alllnr:lilll Central Services - lAS/IPS. etr.., )

5. Designation _.. NO/l-Gazettell

5- Pay Blind( (or Serving Employoc!;)

7. Officlol Addrcs~ ~.....

.•. Prc~elll: Pi1Y .G/'ad~ Pov

8. Residential Addrc~~:

9. Telephone Number: ( 0 ) (R) (M)

to. e-men ro

11. Pate of Supcrannuatlon. __ I __ I _DlItc Month YOl1r

12. Aro you on Deputation (Central Deputation) yc~ I No

l3. tr ves, likely date completion ot Deputation

14. Are your services tr01n:1fer<!llllc to other cities: ves I No

15, oerans of Fllmlly(- Picllfoe SCe dl'lrlnlllon of Fllmllv befoee nlllnQ up thl!; COlumn)S.No. Nllmo of FilrYllly member Name In Hlndl Rellltlon snlp to oete of Blrthl Blood Group

CGHS Cllrd Holdor* (CompulsOJY) (optlol\;ll)

Self

- . . ---'-'

{I Please attllch Proof of Ilge of ~rtionS rnennoncd above)

16. Are 1111the portion, WhOSD nernes are given llOOvO are dependant upon VDU and ere reSiding wIth VDU? ves 1 No

{PleIlS<lattach proof 01' thC)lr staying wIth you, IIkC)copy of RlltlCln OIrd J Election ID 1 PII!>SPort / IdontltY ClIrd I.suod byCollege/ School 1University I BlInk Pas!I Oook , etc., }

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.17. P~!;te one TD CZlrd sue of Photograph of cnch member o( romlly (/ndudlno ~clf) whose names ~rc propo~()a to beIncluded as part of your family In the specc alven Pclow•

. ..__ ._... -_. "--'.---.---~.--------------- ----

S.NoName

S.No. , .••.....Name

S,No •...... ,Name

SNo .....Nume

S.Nn .NUl11e

S.No " .. ,Nume

S.No.Name

SNo ..... ,N:lIl1C

I Undertake to IntlmMc to CGHS Imllled/ately If there I~ /lny challOClIn dependency criterla of my (IImlly membersIncluded In thl5 appllcatlon form. If [ filII to Illthnlltc and If the CGH5 comes to know of the ch/lngc then the CGI1Sfacility Islioble \0 be wltMrllwn by the CGHSand t.ho CGI'IS and / or ilpproprllltc iluthorlly will be frcc to Initiate MY action agaill$lme,

I undertake to Gurrendar the CGI1$ Cllrd(,) Oil my ICllvln9 the Ministry / orncc: on trarder; retirement;termlnallon. Resl9natlon; 01' on cca~lng to be eligible (or CGHS bcnents. .

1 ccrtll'y rhZlt the In(ormiltlon (urnl:;hed by me in this application ha:; been vCrlflad to be correct and that noInformation hbSbeen conCealedor hes been mlsreprescnted and I stand bv the same.

Encl. Proof or Res:Jdcnc:e I Stav of dependentsProof or IIge or ~CJnl Oh:nblllty certlflcete

Signature of Appllcilnt

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(TO Re FIlLI'P BYTHE SPONSORING AUTHORITY IN CAS~ Of'

Sf'RVING fMPlOYfeS)

The infofrTlot.ion tumished by th~ ilpplicllnt. hllS been lIerlfied and round to be correct.

Shrl/Smt /Kurn~ri •• t OcSloniltloll • in thl~

Ministry / Department / Orgllnl~ntion .. It I~ recommend th.)t II cGl·'5 C~,.d be Issucd to Sllri ISmt../KlIfI1l1ri

.. , Insrructlons 1111110 been issueo to the concerned Divl~lon to srarr d~lIctlr1g CGHS

Subscriptions cvcty month tram the S1IItlry of the <tppllc~nt I CGHS Sub:;crlpllonS are deducted every manU, from rne S~llIry

of the IIpplicllIIl. r am lIuthOI·'~cd sponsoting authority for the issue or CGHS Cllrd ~nd ilpprovlIl of the competent authontv

h.:ls been cbtained,

No.

Signature & N<1m~or the Sponsoring Authorlly

Dru;lgnMlon (Stamp) with Tel. Number

To

The Addltlon!!1 Director/Joint Director CGliS of concerned CGli$ City

13-~1f=1R-2012 12: 13 From: ICf=lR HQ NEW DELHI IN 0091+11+23387293 To: 25841282

..'" ,;.;/ ."

rro OE rn.LED OY THfJ SPONSORING AUTHORITY IN CASE OF SERVING I=MPlOYEt:S ANDPENSIONERI' OF. AUTONOMOUS BODIES COVflREO UNDER CGI1S)

The inrormaticn (urnlsi1od by the apllli(unt has been verified ilnd found to be COrrect. It is rt),ornrlll!nci U1bt a

CGli5 arc! be iSSued to Shri /Smt. /Kumllri " Dcsigniltion . In

t.hi~ Ministry I nepartment I OrgMIZlltlOn. IMtructlol1~ are issued to the concerned D"II~lon to start dedl,l~lIIl9 CGI'15

Subscription5 every month from the 5111alY or the applicant I CGHS Sllb5Crlption~ Me deducted CIIClY month from till! slllbry

of tho appllLlllll. I am ilulllorllc(J spOn~oring iluthorll'y (or CI1C i:;~uQ of COHS Card and approval of the: COfrl~tont authority

h1lG been obtalned.

btllnrlng HOdl~~~U.~II'U~~~AA~tU.'I.u.tudatcd •••'nu.'v •••••• ' ••.• n ••••drnwn on fipnk.

11111 ••••••••••••••••••••••••••••••• ,Bra",ch . n"f'lfw"I~"'II. """" "I1"nl "'f"'-' •.• ,." rOtR, '••1.'1 "llllltl

u In rase of PCli~Jot1crs of Autcncrncus bol1ic~onUt.lcd (or CC;HS r<rCllitlc~.

No.

Slcn~tLlrtl &. Name of the: sponsoring Authority

D~sl9natlon (Stamp) wlt.h Tel. Nun1ber

To

The Addltlonal Director, CGHS(HQ), 9, nlkaner nouse HutlnMts,

Verlfled - by Authorized SignatorY, CGHS(HQl vlllld upto .. ./" ,' .. /,.,,"

CGHS DI~ptm5l1ry Allotted .•••••••••..••••.••••••,•••••••••••••••entltltlrnont

•• ( to be fIIl.,a bV CGHS)

Slanllturc Wll:h St<lrnp

.1 __ ,- 1)~

13-~1AR-2012 12: 13 From: IeAR HQ NEWDELHI IN 0091+11+23387293 To: 25841282

fORM '13.'

CGHS ClIrd No whilc in service ; --------------.--.-- •• ------

L N<JlI1c of the AppllCllnt:

oth(!~ (PI..$pC(ify) L I

3, N~m" I)f Department I service from WhCfC retired

4. Last j>;,V( In (~15~ IJr r'(!nsion~r~)

ail~ic pcn~ion :

5. R~sldenUlll Aodrc~:o;

6. Telephone Number: (R)

7. c-meu rn

(M)

B. D<l~oof Supcrannoanon: --I - _I _Date Month Yellr

51.Det!li(s of F~mny

{O Ple1lSt! see definItion of Fllmlly ~rorc: nlllng UP this column}

S.NO. Name of 1"lImily member Namo In Hlndl Rcllltlon sntp to ~!lIC of al~~~ Blood Group

-. ......•... CGHS CMd I~oldcr· Comnulso .l2p'!lol\~D_Solt

f--- ...•.. - --

f--.

-" '.t--- ...~, ..

- .. - ...

{# PlOIlSO attach Proof of IIgo of Parson5 mentioned above)

10. Artllltl the: pcrsonl whose nllmes arc given above IIrc dependant U~t1 you and ore rCGldlng W1tt1 you? Yes I No

(Please attach proof of their staying wIth VOU• IIko copy or Ration Card I Eloctlon ID I PilS~ Port / Identity Card Issued byCollego / School I University I Blln~ PIISS Book, etc., }

1'1 r:

)1>1jIg

13-~1AR-2012 12: 14 From: IeAR HQ NEWDELHI IN 0091+11+23387293 To: 25841282

,,~..~.

\.

11, r~,:;tc one ID C.,rd :olzc of PhOtogHlph (If ~a(" ,lIen'IlIer of Family (Including ~elf) whose n~rTlC!~••re pr"po~cd to beinrllld.~.~i1~ P,lIt of .¥0V!:.filll1ily 1/1the ~~c~~l!!!lbelow. . .. _._ __ .

S No .Name

SNo, , .N"mc

S.NoName

S..No ..Name

S.No ..NUl1)c

S No ...Name

SNo.,N<lmc

SNo.Name

I undertake to Intlmilt.e to CGI"IS hnmedllltcly If there IG <Jnycl1llngc In dt!pcndency crlterll\ of my fll.nlly rnembert;Included In 11IIs O1ppflcatian form. If I filii to Intlrn~lc IInd If the CGHS COIl1C~to know of the changc then the CGHS f!lcllity is1I11plcto be withdrawn by the C:GHS and the CG~IS /lm! I or ilpproprl~tc ;,uthority will be free to Inltl!ltc Imv action ~g~ln$tme.

! Undcrtilkc to surrender t:he CGHS Card(s) an .:ctlsing to be ellglblo (or CGI1S benefits.

I certify th"t the infomwUan furnished by me In tills ilppllclItlall hlls been verified to be correct end that noinformlltl(ln has been concealed or 11115 been ml~rcprcscntcd Iln(ll stnnd by the sarnc.

encl. Proof of Relldlm~~ I Stay of dl!lp~l1denuProM of IIge ot son! Olllablllty certificateSurnmder Certificate or CGHS ClItd wl1l1e In liervlcoAttosted coplec ot PPO 80,Lnlt Pray c"rtificlltc

00 ba&rinp NO•••.... ",,,.fll •••• ,tott,ltu.n ••dntcd .•... tH •••••••• ,,,,,, •• lIudrawn on Dank ,,,,, .•• ,u.flu ••••• ,llltl ••• u,tu.Drnnch.,1, ••• , •..•. ".,1,.,., •... , •. "", •••••••• '.,11, ..•• / Postal Ordor No..•"''''III''r.,II.' ••• h .. u .••. " .. ,. for ft",." •....•••••... , ..•.•

Signature of Applicant,

'roThe Additional Director, CGHS(HQ), 9, Blkaner Hau5C1I'1utmcntJ;, ShahJlItum ROlld, New Delhi.

( to be filled bV CGHS)

Verified - by Auth()rI~ed Slgnlltory, CGHS(HQ) valid upto / ,./ " I tor Reit of LIre

CGHS Dllipen.ary AlJott.d ••.U." ••• ,'''.'' •••••••• II •••• " ••.•••. "".,,,,, ••••• ,,, ••••

Entitlement I Gonllral Ward I Senll·PrlvlltQ Ward I Prlvllto Wllrd

Slanlltlm~

----

13-MAR-2012 12:14 From: ICAR HQ NEW DELHI IN 0091+11+23387293 To: 25841282

(i:

INSTRUCTIONS

Doflnitioh of family;

(l ) Hlj~band / Wlfc· (0 Fir!:!: wife only)(2 ) Dcpenc1antrill'Cllts / Step Mothr.:r ( in ~as.: of adoptlon , only ~doptlve 8. '101:real parenrs)(3 ) If adoptive (lthcr hil~ more ~hnnone wife, the Ilrst wife only,(~ ) A rcmllle employee hllS a cnotco to il',cludc either her dependent porol1t~ or her depenocnt pnrcnts - in I:)w I opti""

cxcrt"!r,c can be Chllll9cd only once during service •(5 ) Children 111Cludin9legally adopted children. step chlldrQI\ .~nd children tZlken as W1Hd~ ~ub.!ect to Ilia following

cPl1l.11tion~,

Till he starts eBtnlng- 'n[ attains tile allc of O!S yr.i\I'~ ,..~hlch!n'!\r I~c::nrllrL _ ..... ._._ .

(Ii) Dbu(jhl.cr TlII she starts earning or acts rnarncd, irreslJedlvc of the !lge. --l--'I"'-im'-"i"'-'~hlchovcr mny /)() C~r1I~!.'_,. __I

'0i-I)-' 5011 Sul'li:!rino from any permanent Irrcspc::ctivQ or ilgc limit,dl&~blllty 01 :lny kind (phy~lc~1or mental ),,~ l1Nll11~d b0.low

(iv) .. . -OcpcndQl1t' dlvorc~d~ndoncd orSl!p<1rilt(!u rrom thl!lr husband / wldowcddaught~rs and dcpendQnt unrnsrrlcd Idlvor~cd abandonerr or separated from

f- __ --I-.!~jll'd I widowed r.ir.tN~M..-. Q£Q<!IlQ!t,t· Minor brothr.l1~_. __ --L.""'U",' to thcJl.Dl'! Of I:lr.C0I11U.19 ..!.'.Il~ITl!!1~!J.lo!!!r-!... _

Ir(esp~ct.ivo of .;g~-I-II-I1I-t,--" ---'-' _ _ __ ._ .

For ~hc purpose of IIvlllllno CGHS tllcHl1y for ~ disabled ~ons above 25 vears , ptcosc attach ~ copy or n the certificate ofdl~B!Jlllty 1~~1Jedby the competent authority.

'Dlsablllty' will be AS DEflNI!D IN SECTlON 2(1) OF 'TI-iI: PERSONS WITH DISAB\lmES (EQUAL OPPORiUNrTlf5,PROTEcnON OF RIGHTS AND ruu PARnCIPATlON ) ACT ,1995 (NQ: 1 OF J996 )' W~IJC;H IS REPRODUCED BELOW:"(1) "DISABILITY'MF.:AN5

(I) BLlNDNf.SS(11) lOW vrSION(lIJ) LEPRQCY CURCD(IV) HEARING TMPAIRMfN1'(V) LOC;OMOTOTR D1SABlLIIY(Vl) MfNTAL RETARDATION(VII) MENTA\..ILLNESS"(vIlT)

OopendonCyI

M~hlbcr.: of rllmllv (other t.hlln ':POUIlO) whosll Income IJ len ~hlln RI.3S00/+0A. per mOhth are trQD~edUd.pondants IInd ore normlllly nn:lding with CGHS bonetldllry.

Th(l FollowIng Documents are to b(l enclosed by pensioners applvlng tor Inuo o( new ponslonerll CGHS Card.(I) Proof of RIl~ldenr.o I Sbly of dep~ndcn~ -{ copy 0' RMlon Card / flection ID / PII$SPort: I Identity

card Issued by Collcge I School 1 Ul1lvcrslty / OM\( Pass Book , etc..)(11) Proof of ago of lion'(Ill) Atto.:ted Copy of Dlsllblllty certificate Ilsuod by Compotflnt Authorlty( In cue ot dependent

lion lIged 25 Ilnd abovlI )for Ponclono!lj applylnll for CGHS card tor the First time the following AddltlonDI nocuments am roqultedl

(IV) Surrender Cartlflcato o( CGHS Card while In corvlcc.(V) Attocted copies of PPO I !.an PIlV Certlflcato

Contribution by Pcnslonert should be made bV Bonk Draft ( Schedulod panks ) payable In Delhi In tllvour or"PIlY. Accounts Offleer CGIiS I Now Dolhl-,

13-MRR-2012 12:14 From: ICRR HQ NEW DELHI IN 0091+11+23387293 To:25841282

FORM 'C'

(To be submitted In dupllcate)

Name 01 Ministry jOt"parl meru

Challan of requtsnfcns of CGHS Cards sent. (,0 the ofIlet' of Additional/JointDlrectur. CGHS

(To be sent In duplicate}

Total No. of AppllcattonsS, No. Reference No,requtsttloned

Date For whom

Nnme/DMlgnatlon

Receipt Stamp

CGHS Cards are likely to be readyFor delivery on _

SIgnature of Despatcher .Name in Block letters .

-

13-~1AR-2012 12: 14 From: IeAR HQ NEWDELHI IN 0091+11+23387293 To: 25841282

...•...";

FORM'D'

Shrt " " Dl'>tllgnntlon holder of Identity CardNo, I~ fII.llh(lrt:~I~dto deliver tilt! Requisitions for Issue or CGHSCards and also to collect the CCliS Cards,

His specimen signatures are given below

Specimen SlgnatureaL _

2. _

Signature of the Sponsoring Authority

Slgnalt.lI·e of the recipient

Received IleoI'd Notsl.

Date & Time

17//8"

-

13-MAR-2012 12:14 From: ICAR HQ NEW DELHI IN 0091+11+23387293 To: 25841282

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~ cri•.,e- .. 1-- ~~.... . -

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2 ifS ID~rJ ~8 8-

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