BHARAT SANCHAR NIGAM LIMITED

(A Government of India Enterprise) Office of CGM Data Network Circle, New Delhi APPLICATION FOR ISSUE OF BSNL MRS MEDICAL IDENTITY CARD Name Designation Staff No (HRMS No) Residential Address : : : :

Have you come on transfer from other Circle? If so, mention the date of joining DNW circle and place of posting

Whether you were issued with BSNL MRS : Card in your previous circle? If so, have you Surrendered the same to the controlling officer? Attach the surrender Certificate. Details of Family Members Sr No Name of the family member 1 2 3 4 5 6 : Date of Birth Relationship

CERTIFICATE I Hereby declare that : 1. My father or father-in-law/ Mother or Mother-in-law is/ are wholly dependent upon me and that he/she/they normally reside with me in The total monthly income of my father or father-in-law/ Mother or Mother-in-law does not exceed my pay plus dearness pay (where applicable) and that it does not exceed Rs 1500/- per month 2. My sons/daughters/step children/widowed daughters and dependent divorced / separated daughters including widowed sisters, minors brothers and dependent brothers as defined under CS(MA) rules included in the list are unemployed and wholly dependent on me. In the event of discontinuance of dependency, I undertake to intimate and request for cancellation. 3. My Husband/wife whose name is included in the list a. is employed at and is not having any medical facility at his/her employees department. b. is employed at and is having medical facility c. is not employed anywhere and no medical facility is available other than that of BSNL MRS. 4. 5. I undertake to surrender the medical identity card on my leaving the corporation/office on transfer/retirement/termination of service/ resignation etc. I also enclose my family group photo as required Office address :

Signature of Govt Servant & designation Endt NoDated atthe.. Forwarded to : The AGM(Admn), O/o CGM, DNW Circle, New Delhi for issue of BSNL MRS Medical Identity card. Signature of controlling officer With seal.

ANNEXURE - B BHARAT SANCHAR NIGAM LTD. BSNL EMPLOYEES MEDICAL REIMBURSEMENT SCHEME
REGISTRATION FORM 1. Name of Employee: 2. Designation: 3. Place of posting: 4. Staff No.: 5. Basic Pay: 6. Telephone: (Office)------------------- (Residence) ----------------------7. Details of Family Members: Sl. No. Name Date of Birth Relationship Blood Group with employee (If available)

8.

Details of chronic disease, if any: a)--------------------b)--------------------c)--------------------d)--------------------9. Options for outdoor treatment (under BSNLMRS):(tick any one of i), ii) or iii) ) i) Outdoor/Domiciliary treatment from RMPs: Reimbursement against vouchers (as per Para 2.1.0). ii) Outdoor/Domiciliary treatment: Entitlement without voucher(as per para 2.1.1) iii) Outdoor/Domiciliary treatment from P&T Dispensaries (as per Para 2.1.2) Declaration: I hereby declare that above mentioned members of my family are fully dependent on me i.e. their income from all sources does not exceed Rs. 1500/- per month. If the above information is found to be false at any time, company can take action against me as per rules or as deemed fit. (Signature of Employee) FOR OFFICE USE ONLY REIGSTRATION NO. ISSUED-------------------CARD ISSUED : YES/NO on ---------------------(Date of issue) Signature of Issuing Authority

ANNEXURE A MEDICAL FACILITY FOR BSNL EMPLOYEES OPTION FORM

1. 2. 3. 4. Name of Employee: Designation: Place of Posting: Options for availing Medical Policy: i) CGHS ii) BSNLMRS Details of CGHS Card, if any i) CGHS Card No.:

5.

I, do, hereby certify that I have gone through the notification of BSNL Medical Reimbursement Scheme and am exercising my option after satisfying myself about various provisions under BSNLMRS.

(Signature of Employee)