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HEALTH CARD FORM

UNIVERSITY COLLEGE OF MEDICAL SCIENCES
(UNIVERSITY OF DELHI)
DILSHAD GARDEN, DELHI-110095.

For Issuance of Identity Card for MEDICAL TREATMENT in approved Hospitals of Delhi University


Acknowledgement No:   
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(Please note down Acknowledgement No for future reference)

Health Centre Book No. (if any)
(In case of Health Centre Members)          
                                                              Paste photograph here
  1. Name in Full(in capitals)    

  2. Father's/Husband's name   

  3. Designation                   Department                 

  4. Present Pay as on                   Pay in Pay Band                  Grade Pay 

    1. Residential Address   
      as admitted in the official records

    2. Mobile No   

    3. E-Mail Id   

  6. Date of initial appointment                   Date of retirement 
Details of Family Members as per CS(MA) rules (dependent & admitted)

S. No. Name Date of Birth Age Relationship

                                                                                                                                               signature
                                                                                                                                              
Employee Signature

FOR OFFICE USE ONLY

Unique I.D. No.:                                Category:                                       Verified By:                              

Date of Issue:                                                   Valid Upto                                                 


Attach separate passport size colored photograph of the employee and his/her declared and admitted dependent family members as per serial number mentioned in the table on the reverse.
(To be affixed within the box only)
(Please do not staple)

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INSTRUCTION/ GUIDELINES:
  1. For availing the facility under direct payment, the beneficiary must carry the following:
    1. Identity Card issued from College
    2. Medical I-Card
    3. If retired, Copy of WUS Health Centre Card (Photocopy of all above, duly self attested should be submitted to the Hospital)
  2. Do not insist upon admission for investigation or for Health Check-up
  3. Expenditure towards Registration/Admission charges, Extra bed for attendent, Expenses on luxury items like Radio/TV/AC/Laundry/Telephone, expenses on vitamins/tonic if not related to treatment, food and beverages for attendent are not payable under Direct Payment Facility.
  4. At the time of discharge medical I-card holder must leaveback all the documents and also sign on the bill. Family Members defination as per CS(MA) rules


I have read the above Instruction/Guidelines.

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Employee Signature

NOTE:
Misuse of Medical I-card Under Direct Payment Facility is a criminal offence.
Suitable action including cancellation of medical I-card shall be taken in case
of willful suppression of facts or submission of false information/statements.
Suitable disciplinary action shall be taken in case of serving employees.