APPLY FOR MEDICAL ASSISTANCE SCHEME

NAME OF PATIENT*
FATHER'S NAME*
MOBILE NO.*
ADHAAR NO.*
ANNUAL INCOME*
BANK A/C NO.*
IFSC CODE*
PERMANENT ADDRESS*
UPLOAD DOCUMENTS

ANNUAL INCOME CERTIFICATE**
PARIVAR REGISTER NAKAL*
DOCTOR'S/HOSPITAL SLIP*
HOSPITAL BILLS*
EMERGENCY CERTIFICATION FROM CMO IN CASE OF TREATMENT IN PRIVATE HOSPITAL
ADHAAR CARD*
ANY OTHER DOCUMENT/ COPY OF PASSBOOK ETC.
“I hereby declare that information furnished above is true and correct in every respect and in case any information is found incorrect even partially the application shall be liable to be rejected.”*

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