Non Covered Certificate for Under EHS

Non Payment CERTIFICATE

         This is to certify that, Sri/Smt .................. working as .....
............ and he/she has taken treatment for (Selfl Dependent) amely disease at for the for the period from ....... and said procedure name/disease name are not covered under 204 procedures as per the EHS Rates which are preseribed in G.O.RtNo:291 Health Medical and Family Welfare(I.I) Dept, dt:12.07.2018 and G.O.Ms.No:345 Health Medical and Family Welfare Dept, dt:21.08.2018, he/she is eligible for subject to responsibility of this hospital and the Hospital Recognition is upto claiming medical reimbursement of Rs.........

Signature of the concerned Doctor with Hospital Seal

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