Download HRA Declaration FormWest Bengal Health Scheme Form Download
Last Updated on November 6, 2019 by WBPAY
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 | |