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Main CardHolder's Personal Information
Enter Benid
Name :
Date Of Birth :
Relation :
Select Relation
genderrelationhidden :
Select gender
genderrelationhidden :
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Gender :
Select Gender
Blood Group :
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A+
B+
Mobile No.:
E-mail Address:
Residential Address:
PAN Number:
Pin Code
State :
Select State
District :
Select District
CGHS Covered City
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Concerned AD's Office
Wellness Center
Select Wellness Center
ID Proof Type:
Select ID Proof
ID Proof
*
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(Only .pdf, .jpg, .jpeg, .png, Files are allowed upto 200 KB)
Residence Proof Type:
Select Residence Proof
Residential Address Proof
*
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Beneficiary Pensioner Department Details
Organization Name :
Select Organization
Organization Name (DDO Code):
Select Organization Name (DDO Code)
Card Type:
Card Category
Card Category:
Card SubCategory:
Select Card SubCategory
Pay Level :
Pay Scale
Last Basic Pay (in Rs.):
Pay Scale Value
Basic pay Level :
Select Basic Pay Level
Ward Entitlement :
Select Entitlement
Fixed Medical Allowances (FMA)
Facility :
Pension proof :
Card Apply Validity :
PPO Number:
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*
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(Only .pdf, .jpg, .jpeg, .png, Files are allowed upto 200 KB)
Date Of Retirement :
Do You Want to Add Dependent Details?
Add Dependent Details
Dependent Name :
Date Of Birth :
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Relation :
Gender :
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Blood Group:
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A+
B+
Upload dependent's photo
Please upload photos in JPG or PNG format, with a maximum file size of 10 KB.
Dependent Proof Type :
Dependent ID Proof
*
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Upload
(Only .pdf, .jpg, .jpeg, .png, Files are allowed upto 200 KB)
Dependent Age Proof Type :
Dependent Age Proof
*
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(Only .pdf, .jpg, .jpeg, .png, Files are allowed upto 200 KB)
Dependent Marriage Proof Type :
Dependent Marriage Proof
*
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(Only .pdf, .jpg, .jpeg, .png, Files are allowed upto 200 KB)
Spouse Proof Type :
Joint Declaration:
*
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(Only .pdf, .jpg, .jpeg, .png, Files are allowed upto 200 KB)
Is Disable?
Disability proof Type:
Disability Certificate:
*
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(Only .pdf, .jpg, .jpeg, .png, Files are allowed upto 200 KB)
Income proof Type:
Income Status Certificate:
*
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(Only .pdf, .jpg, .jpeg, .png, Files are allowed upto 200 KB)
Add Details
Dependent Details
Sr. No.
Name
DOB
Gender
Relation
Photo
Action
Add Nominee Details
Nominee Name :
Date Of Birth :
Relation :
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Gender :
Select Gender
Mobile No:
Address :
Nominee Declaration Proof:
*
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Alternate Nominee Details (if any)
Alternate Nominee Details
Nominee Name :
Date Of Birth :
Relation :
Select
Gender :
Select Gender
Mobile No:
CGHS Ben Id(if exist)
Address :
Aadhar No.(optional)
Alternate Nominee Proof:
*
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Undertaking by Applicant
I,
, solemnly affirm and declare as follows:
Select All Undertaking
That the combined monthly income (from all sources including income accruing from house/other immovable property/fixed deposit etc) of any of my dependents (spouse excluded) is less than Rs 9000/- plus DA.
That my parents or parents-in-law (father/mother or both) do not draw any pension from Central Govt/State Govt/PSUs/any Private Organisation and are normally residing with me.
That my daughter(s)/sister(s) is/are NOT married or is divorced or is widowed and fully dependent on me.
I shall inform the CGHS immediately of any dependent earning more than Rs 9000/- plus DA (monthly income).
That in case of any change in the status of my dependents (due to death, marriage, employment), I will inform CGHS at the earliest and will stop use of CGHS facilities by such dependent. I will refund in full, the cost of any treatment that my dependent may have received after he/she became ineligible. I shall be liable for civil/criminal action should I fail to do so.
That I am NOT a member of any other medical scheme funded by Central Govt, PSU or any other Govt undertaking.
That my spouse is NOT a member of CGHS or any other Govt Scheme.
I understand that in case I have submitted any incorrect information, or if my or my dependents CGHS Card is misused or used by any unauthorized person, my membership will be cancelled without any notice or further hearing. In addition, I will forfeit my contribution and I will pay the entire cost of expenditure incurred on such unauthorized person(s). I will also be liable for legal action by the CGHS organization. I will also immediately report the loss of my CGHS membership card to the nearest CGHS unit.
That in case of any misuse of my CGHS card or tampering with bills or attempt to defraud, once I become a member, I will forfeit my membership automatically.
I undertake that in case of any misbehavior, on my part with any CGHS employee, my membership may be suspended/canceled/terminated, if proven.
I understand that the CGHS subscription/contribution I am making is not refundable even if I do not make use of any CGHS facility or opt out of the CGHS Scheme.
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CGHS Undertaking
I,
, solemnly affirm and declare as follows:
Select All Undertaking
That in case of any misuse of my CGHS card or tampering with bills or attempt to defraud, once I become a member, I will forfeit my membership automatically.
I undertake that in case of any misbehaviour, on my part with any CGHS employee, my membership may be suspended/cancelled/ terminated.
I understand that the CGHS subscription/ contribution I am making is not refundable even if I do not make use of any CGHS facility or opt out of CGHS Scheme.
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Please Review Below Application and Click Save to submit application
APPLICATION FOR NEW CGHS CARD
Acknowledgement No. :- #trackingId#
Name of the Applicant:
id="dialogName">
Category /Subcategory:
/
Mobile:
E-mail Id:-
Residential Address:-
PinCode:-
State:-
/
CGHS City:-
Last Pay / Basic Pension (in case of Pensioners):-
Scale of Pay:
Date of retirement/superannuation:
Pension related:
Do you have PPO?
PPO number:
Are u availing Fixed medical allowance (FMA):
Card validity: -as chosen by applicant from drop down-
Eligible for:
Details of Family
S.No
Name of Family Member
Date of Birth
Relationship
Gender
Details of Nominee
S.No
Name of Nominee
Date of Birth
Relationship
Gender
Mobile No.
{# Please attach Nominee form}
CGHS Undertaking by Main Card Holder
I,
, solemnly affirm and declare as follows:
✔ That the combined monthly income (from all sources including income accruing from house/other immovable property/fixed deposit etc) of any of my dependant (spouse excluded) is less than Rs 9000/- plus DA.
✔ I shall inform the CGHS immediately of any dependent earning more than Rs 9000/- plus DA (monthly income).
✔ That in case of any change in the status of my dependents (due to death, marriage, employment), I will inform CGHS at the earliest and will stop use of CGHS facilities by such dependant. I will refund in full, the cost of any treatment that my dependent may have received after he/she became ineligible. I shall be liable for civil/criminal action should I fail to do so.
✔ That I am NOT a member of any other medical scheme funded by Central Govt, PSU or any other Govt undertaking.
✔ That my spouse is NOT a member CGHS or any other Govt Scheme.
✔ I understand that in case I have submitted any incorrect information, or if my or my dependents Card is misused or used by any unauthorised person, my membership will be cancelled without any notice or further hearing. In addition, I will forfeit my contribution and I will pay the entire cost of expenditure incurred on such unauthorised person(s). I will also be liable for legal action by the CGHS organisation. I will also immediately report the loss of my CGHS membership card to the nearest CGHS unit.
✔ That in case of any misuse of my CGHS card or tampering with bills or attempt to defraud, once I become a member, I will forfeit my membership automatically.
✔ I undertake that in case of any misbehaviour, on my part with any CGHS employee, my membership may be suspended/cancelled/terminated, if proven.
✔ I understand that the CGHS subscription/ contribution I am making is not refundable even if I do not make use of any CGHS facility or opt out of CGHS Scheme.
UNDERTAKING BY SPONSORING AUTHORITY
✔ To be filled by Head of Department where CGHS card applicant is posted) (Please tick () checkboxes as applicable) The information furnished by the applicant has been verified and found to be correct. It is recommended that a CGHS Card be issued to Shri/Smt./Kumari-insert name of main card holder, at basic pay -insert from application and Pay level -insert from application-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 the authorized sponsoring authority for the issue of CGHS Card and approval of the Competent Authority has been obtained
Please Review Below Application and Click Save to submit application
APPLICATION FOR NEW CGHS CARD
Acknowledgement No. :- #trackingId#
Name of the Applicant:
Category /Subcategory:
/
Mobile:
E-mail Id:-
Residential Address:-
PinCode:-
State:-
/
CGHS City:-
Basic Pay (in Rs.):-
Scale of Pay:
Employment related:
Department:
Are you under Deputation.
End Date of Deputation.
Details of Family
S.No
Name of Family Member
Date of Birth
Relationship
Gender
CGHS Undertaking by Main Card Holder
I,
, solemnly affirm and declare as follows:
✔ That the combined monthly income (from all sources including income accruing from house/other immovable property/fixed deposit etc) of any of my dependant (spouse excluded) is less than Rs 9000/- plus DA.
✔ I shall inform the CGHS immediately of any dependent earning more than Rs 9000/- plus DA (monthly income).
✔ That in case of any change in the status of my dependents (due to death, marriage, employment), I will inform CGHS at the earliest and will stop use of CGHS facilities by such dependant. I will refund in full, the cost of any treatment that my dependent may have received after he/she became ineligible. I shall be liable for civil/criminal action should I fail to do so.
✔That I am NOT a member of any other medical scheme funded by Central Govt, PSU or any other Govt undertaking.
✔ That my spouse is NOT a member CGHS or any other Govt Scheme.
✔ I understand that in case I have submitted any incorrect information, or if my or my dependents Card is misused or used by any unauthorised person, my membership will be cancelled without any notice or further hearing. In addition, I will forfeit my contribution and I will pay the entire cost of expenditure incurred on such unauthorised person(s). I will also be liable for legal action by the CGHS organisation. I will also immediately report the loss of my CGHS membership card to the nearest CGHS unit.
✔ That in case of any misuse of my CGHS card or tampering with bills or attempt to defraud, once I become a member, I will forfeit my membership automatically.
✔ I undertake that in case of any misbehaviour, on my part with any CGHS employee, my membership may be suspended/cancelled/terminated, if proven.
✔ I understand that the CGHS subscription/ contribution I am making is not refundable even if I do not make use of any CGHS facility or opt out of CGHS Scheme.
UNDERTAKING BY SPONSORING AUTHORITY
✔ To be filled by Head of Department where CGHS card applicant is posted) (Please tick () checkboxes as applicable) The information furnished by the applicant has been verified and found to be correct. It is recommended that a CGHS Card be issued to Shri/Smt./Kumari-insert name of main card holder, at basic pay -insert from application and Pay level -insert from application-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 the authorized sponsoring authority for the issue of CGHS Card and approval of the Competent Authority has been obtained
Instructions to card applicant:
i. Take printout of the duly filled form.
ii. Attach self-attested copies of all supporting documents that were uploaded online.
iii. Request sponsoring authority of your concerned department to do the needful with respect to Pg.3 i.e., "Undertaking by Sponsoring authority."
iv. Please submit the duly filled and department forwarded CGHS card application form along with supporting documents to the O/o Additional Director of CGHS in your city.
v. Kindly note down the Acknowledgement number at the top of the form. This Acknowledgement number shall enable you to track the status of your card application.
Acknowledgment Number: