Here are all required WB Health Scheme Form for West Bengal Govt Employees, Pensioners, DDO/HOO and empaneled Hospitals.
Click here to view the new revised form (Updated on 22/10/2019)
WB Health Scheme Form for Employees:
| Description | Form No | Download Link |
|---|---|---|
| Application for enrolment | Form-A |  |
| Application Form for settlement of claim for reimbursement | Form-C | |
| Checklist For Reimbursement of Medical Claims | Form-E | |
| Essentiality Certificate for Indoor/Day Care treatment & related OPD treatment | Form-D2 | |
| Essentiality Certificate for treatment in Health Scheme non-recognised H.C.O.s | Form-D3 | |
WB Health Scheme Form for Pensioners:
| Description | Form No | Download Link |
|---|---|---|
| Application for enrolment | Form-I | |
| Application Form for settlement of claim for reimbursement | Form-III | |
| Certificate of enrolment (Government pensioner/ family pensioner) | Form-II | |
| Checklist For Reimbursement of Medical Claims | Form-V | |
| Essentiality Certificate for Indoor/Day Care treatment & related OPD treatment | Form-IV2 | |
| Essentiality Certificate for OPD treatment | Form-IV1 | |
| Essentiality Certificate for treatment in Health Scheme non-recognised H.C.O.s | Form-IV3 | |
| Prayer for Changing Sanctioning Authority in Connection with WBHS 2008 | Form-VII | |
WB Health Scheme Forms for DDO/HOO:
| Description | Form No | Download Link |
|---|---|---|
| Generation of CARC from Health Portal | 51-F(MED)WB | |
| Treasury form requires for submission of Health Scheme claim at Treasury/PAO | T.R. Form No. 68 | |
| Description | Form No | Download Link |
|---|---|---|
| Application Form of Empanellment under WBHS | Application | |
| Essentiality Cum Expenditure Statement for Cashless Indoor Medical Treatment. | Form-D4 | |
| Information Sheet for Cashless Indoor Medical Treatment | Form-H | |
| Memorandum of Agreement (MOA) | 141-F (Med) | |
| Procedure and guidelines for online functionaries of Health Portal | Online Billing | |
| Rate Charts | Rate Charts | |
