Annexure-VII
FORM - C
(Application for Self Treatment under Mediclaim Scheme)
Name:-.............................................
Address:-.........................................
.......................................................
Dated:- / /
To,
The Director,
Directorate of Health Services,
Panaji Goa.
Sub: Treatment under Mediclaim Scheme.
Sir,
I have to proceed to ....................................................... (place)for Medical treatment at
.................................................................................. ( Name of Hospital) as required under the
scheme, I am submitting herewith the following certificate:-
(i) Certificate from the Medical Superintendent, Goa Medical College/Directorate of Health Services that facilities for my treatment are not available.
(ii) Certificate from the Mamlatdar of ........................................
certifying that total income of my family members does not exceed Rs. 1,50,000/- per annum and that I am registered in the voter's list.
OR
(iii) Certified copy of the P.P.O. bearing No. .................. confirming that the patient is a retired State Government Employee.
I shall be obliged if a letter recommended me for medical treatment at
............................................................................. (name of hospital) is kindly issued to me immediately for admission in the hospital.
Yours faithfully,
Encl: As above.
( Signature )