Annexure - VIII
FORM - D
(Application for treatment under the Mediclaim to be submitted on behalf of the patient
when the patient is minor)
Name:-.............................................
Address:-.........................................
.......................................................
Dated:- / /
To,
The Director,
Directorate of Health Services,
Panaji Goa.
Sub: Treatment under Mediclaim Scheme.
Sir,
My ........................................................ ( relationship) ................................
......................................................................................... (name of the patient) is to be taken to ................................................. (place) for medical treatment at ..................................................................................... (name of the hospital) as required under
the scheme. The following certificate are submitted:-
(i) Certificate from the Medical Superintendent, Goa Medical College, Bambolim that facilities for his/her treatment are not available in this State.
(ii) Certificate from the Mamlatdar of ........................................ (taluka) that the total income of my/his family does not exceed Rs.1,50,000/- per annum and that he/she is registered in the voter's list (not
applicable if minor)
(iii) Certified copy P.P.O. bearing No. .......................... certifying that the patient is a retired Government employee.
I shall be obliged if a letter recommending him/her for treatment .................................................................................................... ( name of the hospital, Place) is
kindly issued to me immediately for admission in the hospital.
Yours faithfully,
( Signature)