Annexure - IX
No: DHS/MED/F. / /
Directorate of Health Services,
Campal, Panaji Goa
Dated:
FORM - E
(Format of undertaking to be given to the Hospital/patient in respect of treatment and payment)
Dear Sir,
This is to certify that Shri/Smt. ....................................................................
is eligible for benefits under Mediclaim Scheme of Government of Goa.
The reimbursement per illness under the Mediclaim Scheme will be limited to Rs.
1,50,000/- or actual Hospital expenses, whichever is the least, in respect of the following:-
(1) Room, board and nursing expenses including surcharge, if any limited
to Rs. 250/- per day;
(2) I.C.U.;
(3) Surgeon's and Anaesthetists fees;
(4) Anaesthesia, blood, oxygen, operation theatre, surgical appliances;
(5) Diagnostic materials and X-Ray;
(6) Medical practitioner's, consultants and specialists fees;
(7) Medicines & Drugs.
Shri/Smt. ___________________________________________________
has been advised ___________________________________________________
__________________________________________________________________
We enclose a xerox copy of the certificate dated ________________ issued by the
Medical Superintendent, Goa Medical College and undertake to reimburse you upto Rs.
1,50,000/- on receipt of your bills.
Kindly admit/him/her and render necessary treatment and send us the claim form and your bills, duly signed by the patient, for settlement.
Thanking you in anticipation.
Yours faithfully,
Director of Health Services.
Copy forwarded to:-
(1) Shri/Smt. ______________________________________________________
______________________________________________________________
(2) Jt. Secretary (Health), Public Health Department, Secretariat Annexe, 3rd Floor, Junta House, Panaji, Goa, for information.