West Bengal Health Scheme Form Download

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:

Forms for Hospitals:

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

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