TRM 1 (Item XI of Part A of Annexure I to Chapter 8) Application for release of exchange for medical treatment abroad Documentation 1. An estimate of expenses from the overseas doctor/hospital. 2. Passport of the patient and attendant/s. 1. Details of the patient (a) Name (a) (b) Address (b) (c) Nationality (c) (d) Passport No. & date (d) (e) Passport issued at (e) 2. Nature of the ailment 3. Expected duration of treatment (i) In hospital (i) (ii) Pre/Post hospitalisation (ii) 4. Exchange requirement for the patient (a) For medical treatment including hospitalisation (a) (b) For pre/post hospitalisation stay (Living and incidental expenses) (b) 5. Exchange requirements for attendant/s (if recommended by the doctor) (a) Name/s & address/ of the attendant/s (a) (b) Amount of exchange required and number of days (b) 6. Any other relevant information DECLARATION I hereby declare that the statements made above are true to the best of my knowledge and belief. I also declare that I/the patient have/has not submitted and will not submit any application for the same purpose to any other branch/office of any authorised dealer in foreign exchange in India. I further undertake to submit within a period of 30 days of my/the patient's return to India, a statement of account of the expenses incurred abroad, duly supported by bills, where necessary, together with a certificate from the attending physician/surgeon that I/the patient have/has undergone the treatment. ...................................................... (Signature of patient/applicant) Place: .......................... Date: .......................... _____________________________________________________________________________ Certificate from the Treating Physician/Surgeon 1. Brief description of the ailment 2. Specific reasons for which a visit to a specialist/institution in a foreign country is necessary 3. Estimated period of treatment abroad I certify that I have satisfied myself that the ailment from which the patient is suffering is of such a nature that treatment abroad is necessary. Signature____________________________________ Name of the applicant _________________________ Registration No.______________________________ Address: ____________________________________ Place:........................ Date:........................
