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Isha Health Care
Form
form 2
Form
form 2
Reimbursement Application Form
ISHA HEALTH CARE WELFARE ASSOCIATION
Application form for Reimbursement
PART A: TO BE FILLED IN BY THE PATIENT/APPLICANT
Aadhaar Card No:
Name of the Patient:
Mobile Number:
The Patient is:
Live
Dead
Live Patient Details:
Name of the Applicant:
Applicant Aadhaar Card Number:
Deceased Patient Details:
Name of the Applicant:
Relationship to the Patient:
Birth/Death Certificate No.:
Date:
Place:
Volunteer Number:
📌 Upload Mandatory Enclosures:
Photo of the Patient:
Evidence for Treatment (Intra Operative Photo, Case Sheet):
Copy of Aadhaar Card of the Patient/Applicant:
Copy of Lab/X-ray/CT/MRI Reports (Pre-treatment):
Final Consolidated Bill:
Original Discharge Summary:
Copy of X-ray, Scan, Biopsy Reports (Post-treatment):
Copy of Hospital Registration Certificate:
Copy of First Page of Bank Passbook:
Copy of Family Member Certificate (if deceased):
SUBMIT