Health Department APPLICATION FOR CGHS CARD Applying for New CGHS Card -in case of new pensioner's Card- CGHS Card No. while in service Applying for New Card to replace existing CGHS Card No. 1. Name of the Applicant: ..................................... 2. Category Departmental Services Pensioners Others (Pl.Specify) ............... { Please Tick Departmental if you are posted in the Ministry of Health & Family Welfare/ DGHS / CGHS } { Please Tick Services if you belong to any specific organized service } 3. Name of Department / Service 4. Designation ................ Gazetted Non-Gazetted 5. Scale of Pay .................. Present Pay ......................... 6. Last Pay / Basic Pension ( in case of Pensioners):.............................. 7. Official Address :.............................................. ............................................... 8. Residential Address:............................................. ............................................. 9. Telephone Number: ( O ) ( R ) ( M ) 10. e-mail ID 11. Date of Superannuation: 12. Are you on Deputation (Central Deputation) _ _ / _ _ / _ _ _ _ Date Month Yes / No Year 13. If yes, likely completion of Deputation 14. Are your services transferable to other cities: Yes / No 15. Details of Family {* Please see definition of Family before filling up this column} S.No. Name of Family member Relation ship to CGHS Card Holder* Date of Birth# Blood Group (optional) Self {# Please attach Proof of age of Persons mentioned above} (P.T.O.) 16. Are all the persons whose names are given above are dependant upon you and are residing with you? Yes / No {Please attach proof of their staying with you , like copy of Ration Card / Election ID / Pass Port / Identity Card issued by College / School / University / Bank Pass Book , etc., } 17. Paste one ID Card size of Photograph of each member of Family (including self) whose names are proposed to be included as part of your family in the space given below. S.No ..... S.No. ... S.No.... S.No.. S.No... S.No ..... S.No. ... S.No.... S.No.. S.No... I Undertake to intimate to CGHS immediately if there is any change in dependency criteria of my family members included in this application form. If I fail to intimate and if the CGHS comes to know of the change then the CGHS facility is liable to be withdrawn by the CGHS and the CGHS and / or appropriate authority will be free to initiate any action against me. I Undertake to surrender the CGHS Card(s) on my leaving the Ministry / Office on transfer; retirement; termination. Resignation; or on ceasing to be eligible for CGHS benefits. I certify that the information furnished by me in this application has been verified to be correct and that no information has been concealed or has been misrepresented and I stand by the same. Encl. Proof of Residence / Stay of dependents Proof of age of son/ Disability certificate Surrender Certificate of CGHS Card while in service Attested copies of PPO & Lasr Pay Certificate Signature of Applicant. (TO BE FILLED BY THE SPONSORING AUTHORITY) The information furnished by the applicant has been verified and found to be correct. It is recommend that a CGHS Card be issued to Shri /Smt. /Kumari ......................., Designation ............. In this Ministry / Department / Organization. Instructions are issued to the concerned Division to start deducting CGHS Subscriptions every month from the salary of the applicant / CGHS Subscriptions are deducted every month from the salary of the applicant. I am authorized sponsoring authority for the issue of CGHS Card and approval of the Competent authority has been obtained. No. Date Signature & Name of the Sponsoring Authority Designation (Stamp ) with Tel. Number Verified - by Authorized Signatory, CGHS(HQ) Signature with Stamp ( for CGHS pensioners making card First Time) To Chief Medical Officer i/c , CGHS Dispensary No. INSTRUCTIONS Definition of Family: (1 ) Husband / Wife* (* First wife only) (2 ) Dependant Parents / Step Mother ( in case of adoption , only adoptive & not real parents) (3 ) If adoptive father has more than one wife , the first wife only. (4 ) A female employee has a choice to include either her dependent parents or her dependent parents - in law ; option exercise can be changed only once during service . (5 ) Children including legally adopted children , step children and children taken as wards subject to the following conditions: (i) Son Till he starts earning or attains the age of 25 years , whichever is earlier. (ii) Daughter Till she starts earning or gets married, irrespective of the age limit , whichever may be earlier. (iii) Son Suffering from any permanent disability of any kind (physical or mental ) as defined below Irrespective of age limit. (iv) Dependent divorced / abandoned or separated from their husband / widowed daughters and dependent unmarried / divorced abandoned or separated from their husband / widowed sisters Irrespective of age limit. (v) Dependent Minor brother(s ) Upto the age of becoming a major. For the purpose of availing CGHS facility for a disabled sons above 25 years , please attach a copy of n the certificate of disability issued by the competent authority. 'Disability' will be AS DEFINED IN SECTION 2(1) OF 'THE PERSONS WITH DISABILITIES (EQUAL OPPORTUNITIES, PROTECTION OF RIGHTS AND FULL PARTICIPATION ) ACT ,1995 (NO: 1 OF 1996 )' WHICH IS REPRODUCED BELOW: "(1) "DISABILITY' MEANS (I) BLINDNESS (II) LOW VISION (III) LEPROCY CURED (IV) HEARING IMPAIRMENT (V) LOCOMOTOTR DISABILITY (VI) MENTAL RETARDATION (VII) MENTAL ILLNESS " (VIII) Dependency: Members of family (other than spouse) whose income is less than Rs.1500/- per month are treated as dependents and are normally residing with CGHS beneficiary. The Following Documents are to be enclosed: (I) Proof of Residence / Stay of dependents -{ copy of Ration Card / Election ID / Pass Port / Identity Card issued by College / School / University / Bank Pass Book , etc.,} (II) Proof of ag e of son (III) Attested Copy of Disability certificate issued by Competent Authority( in case of dependent son aged 25 and above ) For Pensioners applying for CGHS card for the First time the following Additional Documents are required: (IV) Surrender Certificate of CGHS Card while in service. (V) Attested copies of PPO & Last Pay Certificate Contribution by Pensioners should be made by Bank Draft ( Scheduled Banks ) payable in Delhi in favour of "Pay & Accounts Officer CGHS , New Delhi".
