Mukhya Mantri State Health care Scheme Enrollment and

MMSHCS-HP
Govt. of Himachal Pradesh
Mukhya Mantri State Health care Scheme Enrollment and Declaration Form:
eq[;ea=h jkT; LokLF; ns[kHkky ;kstuk ukekadu vkSj ?kks"k.kk Q‚eZ:
Please go through the instructions before filling up the form. Use capital letters only/ —i;k Q‚eZ Hkjus ls
igys funsZ'k i<+as |
Details of Beneficiary/ykHkkFkhZ dk C;kSjk
1
Full Name of Beneficiary
Family ID (to be
allotted)
ykHkkFkhZ dk iwjk uke
2
Father’s/Husband Name
3
[email protected] dk uke
Mother’s Name/ ekrk dk uke
4
Age/vk;q:
Date of Birth/tUe frfFk:
Gender/ fyax
Male/ iq:"k
Female/efgyk
Other/ vU;
Permanent Address/LFkk;h irk
5
House No./ Building No.
x`g la[;[email protected] uEcj
Village/Town/ City
xkao@'kgj@{ks=
Street/Gram Panchayat/NP
[email protected] iapk;[email protected] iapk;r
Area/Tehsil/Block
[email protected] [k.M
District/ ftyk
State/ jkT;
Pin Code/fiu dksM
6
Gen
SC
ST
OBC
Minority
7
8
Enrollment Category/ukekadu Js.kh
Social Category/ lkekftd Js.kh
Senior Citizen >80 years/80 o"kZ ls vf/kd ofj"B ukxfjd
Average Income
Ekal Naari/,dy efgyk
Part time Worker/ va'kdkfyd
Daily Wage Worker/ nSfud osruHkksxh
Anganwari Worker/ vkaxuokM+h odZj
Anganwari Helper/ vkaxuokM+h lgk;d
Mid- Day Meal Worker/ feM&Ms ehy deZpkjh
Contractual Employee/ vuqcU/k deZpkjh
>70% disabled/70 izfr'kr~ ls vf/kd v{ke
Monthly [
] Yearly [
]
vkSlr vk;
ekfld
Proof of Certificate/ çek.k i=
www.myhealthcareindia.com
www.primehealers.com
okf"kZd
Aadhar card/vk/kkj dkMZ
Voter ID card/ oksVj dkMZ
Birth certificate/ tUe izek.k i=
PAN card/iSu dkMZ
Disability Certificate/ v{kerk izek.k i=
Ekal Nari Certificate//,dy efgyk izek.k i=
Matric Certificate/ nloh ikl çek.k i=
Pass port/ ikliksVZ
Ration Card/ jk'ku dkMZ
Page 1 of 3
MMSHCS-HP
Govt. of Himachal Pradesh
Details of Dependents including self (in case of senior citizens please mention members who are only above
80 years)/vkfJrksa dk C;kSjk Lo;a lfgr (ofj"B ukxfjdksa ds ekeys esa —i;k dsoy 80 lky ls Åij ds lnL;ksa dk C;kSjk nhft;sA
Name
uke
Age/ Date
of Birth
Gender
(M/F/O)
Relationship
Mobile
with beneficiary Number
UID
number
vk;q@
tUe frfFk
fyax
ykHkkFkhZ ds lkFk
lEcU/k
vk/kkj la[;k caSd [kkrk
la[;k ¼;fn gS½
Self-Declaration/ Lo
eksckby uEcj
Bank Account
number
?kks"k.kk
I do hereby certify that the above information is true to the best of my knowledge and belief. It is also
certified that myself along with dependents mentioned above are not availing the benefit of RSBY or any
other Medical Reimbursement scheme.
eSa izekf.kr [email protected] gwa fd mijksDr nh xbZ lwpuk esjs Kku rFkk fo'okl ds vuqlkj lgh gSA ;g Hkh izekf.kr
fd;k tkrk gS fd eSa rFkk mijksä vkfJr jk"Vªh; LOkkLF; chek ;kstuk vFkok fdlh vU; fpfdRlk izfriwfrZ ;kstuk ds
vUrxZr dksbZ ykHk ugha ys jgs gSA
fnukad%
izkFkhZ ds [email protected] fu”kku
Applicant Signature/ Thumb Impression
Department Verification:
(Applicable for Contractual Employees, Part Time/Daily Wage/Anganwari/Mid-day Meal workers,
Anganwari Helpers and Ekal Naris)
Certified that Sh./Smt.______________________is working as Part time Worker/ Daily Wage worker/
Anganwari Worker/ Anganwari Helper /Mid- Day Meal Worker/Contractual employee or belongs to EKal
Nari category and he/she is eligible to get benefit under MMSHCS, HP.
Signature ____________________
Department Seal_____________________
FKO Verification:
It is verified from the documents and details provided by the beneficiary that the person belongs to
_______________________ category and he/she is eligible to get the benefit under the MMSHCS, HP.
FKO Signature___________________
Name_____________________
Date & Time of Enrolment (to be filled by enrollment agency only):
__________________________
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MMSHCS-HP
Govt. of Himachal Pradesh
Instructions/vuqns'k
1. Mukhya Mantri State Health Care Scheme covers only following categories/ eq[;ea=h jkT; LokLF; ns[kHkky ;kstuk
dsoy fuEu Jsf.k;ksa dks 'kkfey djrk gSA
Sl. No
1
2
3
4
5
6
7
8
9
Enrollment Category
Senior Citizens- Above 80 years age
Ekal Naris- Widows, Divorced, Abandoned,
With missing husband and Un-married women
Anganawari workers
Anganawari Helpers
Mid-Day Meal Workers
Persons with more than 70% disability
Contractual Employees
Part time Workers
Daily Wage Workers
Ukekadu Js.kh
80 o"kZ ls vf/kd ofj"B ukxfjd
,dy efgyk -fo/kok, rykd'kqnk, ifjR;ä, ykirk ifr, vfookfgr
vkaxuokM+h dk;ZdrkZ
vkaxuokM+h lgk;d
feM&Ms ehy deZpkjh
70 izfr'kr~ ls vf/kd v{ke
vuqcU/k deZpkjh
va'kdkfyd deZpkjh
nSfud osruHkksxh deZpkjh
2. Only those individuals/dependents who are not covered under RSBY or any other Medical reimbursement Scheme
are eligible to get benefits under MMSHCS/dsoy ogh O;fä/vkfJr bl ;kstuk ds varxZr ik= gksx
a s tks dh vkj ,l ch okbZ vFkok
fdlh vU; fpfdRlk çfriwfrZ ;kstuk ds rgr ykHk ugha ys jgs gS|
3. In case of Senior Citizens the dependents also must be above 80 years/ ofj"B ukxfjdksa ds ekeys esa vkfJrksa dks Hkh 80 lky ls
Åij gksuk pkfg,A
www.myhealthcareindia.com
4. Only Rs. 30/- has to be paid at the time of enrollment/ ukekadu ds le; dsoy # 30/& dk gh Hkqxrku fd;k tkuk gSA
Documents Required/ vko';d nLrkost
5. One of the following government issued identity card is mandatory for all categories:- Aadhar card/Voter
ID/Pan Card/passport/ration card/ fuEu esa ls ljdkj }kjk tkjh dksbZ ,d igpku i= vfuok;Z gS :- vk/kkj dkMZ/ernkrk
igpku i=/iSu dkMZ/ikliksVZ/jk'ku dkMZA
6.
For senior citizens above 80 years, one of the following age proof certificate is mandatory:- Aadhar/Voter
ID/Pan card/Birth certificate/Matric Certificate/ passport/Certificate of Date of Birth issued by Class-I
Gazetted Officer on Letterhead/80 o"kZ ls Åij ds ofj"B ukxfjdksa ds fy, fuEu esa ls ,d vk;q çek.k i= vfuok;Z gSSA
(vk/kkj/ ernkrk igpku i=/ iSu dkMZ/ tUe çek.k i=/ nloh ikl çek.k i=/ ikliksVZ/ ysVjgsM ij Js.kh&,d jktif=r vf/kdkjh
}kjk tkjh tUe frfFk dk çek.k i=)
7. For Ekal Naris, certification from concerned Panchayat/Nagar Panchayat/Muncipal Corporation/Development Block
or memebership in Ekal Nari Shakti Sangatan is mandatory/,dy efgykvksa ds fy, lEcaf/kr iapk;r / uxj iapk;r/ eqfUliy
dkjiksj's ku /fodkl [kaM ls çek.k i= ;k ,dy ukjh 'kfä laxBu dh lnL;rk vfuok;Z gSA
8. For >70% disabled, disability certificate from competent authority is mandatory/70 izfr'kr~ ls vf/kd v{ke ds
fy, l{ke çkf/kdkjh ls v{kerk izek.k i= vfuok;Z gSA
9. For all other categories, Departmental Certification as given on page no. 2 of form is mandatory/vU; lHkh
Jsf.k;ksa ds fy, foHkkxh; lR;kiu tSlk dh Q‚eZ ds i`"B 2 ij fn;k x;k gS vfuok;Z gSA
Toll free/ Vksy Ýh: 1800 301 00334
Email: [email protected]
Address: HP Swasthya Bima Yojana Society, Dept. of Health & FW, Thakur Villa, Kasumpti, Shimla- 171009
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