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    Wbhs Opd Annexure - I

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    vu3iyu
    The document provides a certification form for claiming reimbursement of outpatient treatment costs under the West Bengal Health Scheme. It lists diseases covered for outpatient treatment and the process for submitting claims with the signed certification form from a treating specialist at a recognized hospital.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Wbhs Opd Annexure - I

    Uploaded by

    vu3iyu
    8K views1 page
    The document provides a certification form for claiming reimbursement of outpatient treatment costs under the West Bengal Health Scheme. It lists diseases covered for outpatient treatment and the process for submitting claims with the signed certification form from a treating specialist at a recognized hospital.

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    Wbhs Opd Annexure - i

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    © © All Rights Reserved

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    The document provides a certification form for claiming reimbursement of outpatient treatment costs under the West Bengal Health Scheme. It lists diseases covered for outpatient treatment and the process for submitting claims with the signed certification form from a treating specialist at a recognized hospital.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    8K views1 page

    Wbhs Opd Annexure - I

    Uploaded by

    vu3iyu
    The document provides a certification form for claiming reimbursement of outpatient treatment costs under the West Bengal Health Scheme. It lists diseases covered for outpatient treatment and the process for submitting claims with the signed certification form from a treating specialist at a recognized hospital.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    For Employee/Pensioner/

    Family Pensioner of Govt. of West Bengal


    Annexure-I
    (As per Order No. 127-F(MED)W, dated 26.11.2021)

    Certification of Treating Consultant/Specialist of a Recognised/Empanelled/Enlisted Hospital


    for claiming reimbursement of “Out Patient Department” treatment for all notified diseases/
    illnesses except Selected Investigations [Vide Clause 10 of Order No. 797-F(MED), dated
    31.01.2011] and Prosthesis & Special Devices under WBHS.

    1. Certified that the Patient, Sri/Smt. , having Beneficiary ID


    , is a beneficiary of West Bengal Health Scheme.
    2. S/he has been suffering from/undergoing follow up (specify
    name of disease) as listed in Sl. No. of the OPD list as per 7(1) / 7(2) clause as mentioned below*.
    3. Date of consultation is .

    Date:
    Signature of the Treating Consultant/Specialist :
    Name of the Hospital :
    Official Seal of the Hospital :

    *List of Out-Patient Department (OPD) diseases and Follow-up Medical Attendance under West Bengal
    Health Scheme.
    As per Clause 7(1) of Order No. 7287–F, dated 19-09-2008 As per Clause 7(2) of Order No.
    7287–F, dated 19-09-2008
    Sl. Name of Disease Sl. Name of Disease Sl. Name of Disease
    No. No. No.

    1 Malignant Diseases. 2 Tuberculosis. 1 Neuro Surgery.


    3 Hepatitis B/C and Other Liver 4 Type 1 Insulin Dependent Diabetes 2 Cardiac Surgery (Including
    Diseases. Coronary Angioplasty and
    implants).
    5 Heart Diseases. 6 Neurological Disorder/ Cerebra 3 Cancer Surgery/ Chemotherapy/
    Vascular Disorders. Radiotherapy.
    7 Malignant Malaria. 8 Renal Failure. 4 Renal Transplant.
    9 Thallasaemia/ Bleeding 10 Injuries Caused by Accident (including 5 Hip/ Knee replacement Surgery.
    orders/ Platelet Disorders. Animal Bite).
    11 Rheumatoid Arthritis. 12 Systematic Lupus Erytthematous 6 Accident cases.
    (LUPUS).
    13 Crohn’s Disease. 14 Endodontic Treatment (Root Canal
    Treatment).
    15 COPD (Chronic Obstructive 16 Ankylosing Spondylitis
    Pulmonary Disease).
    17 Covid-19 18 Selected Investigations [VideClause 10 of
    Order No. 797-
    F(MED), dated 31.01.2011]
    19 Prosthesis and Special Devices. 20 Outstate Prior Permitted OPD Treatment

    Note:
    1. In case of occasional OPD consultation, employee/pensioner/family pensioner can claim reimbursement under
    WBHS only once with original copy of Annexure-I.
    2. In case of continuous OPD consultation, employee/pensioner/family pensioner can claim maximum 2 (Two)
    times reimbursement under WBHS. S/he can submit his/her successive reimbursement claim with photo copy of
    signed Annexure-I only once. Consultation with treating specialist is mandatory after every six months from the
    date of previous consultation for getting further reimbursement under WBHS.

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