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CGHS Card Correction Application Form

This document is an application to correct an error in a plastic CGHS card. It requests the beneficiary's name, ID number, names of up to 7 family members covered, the dispensary, nature of the error needing correction, what correction is required, contact phone number, and includes photocopies of pay slips and CGHS ID cards.

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renganathan
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2K views1 page

CGHS Card Correction Application Form

This document is an application to correct an error in a plastic CGHS card. It requests the beneficiary's name, ID number, names of up to 7 family members covered, the dispensary, nature of the error needing correction, what correction is required, contact phone number, and includes photocopies of pay slips and CGHS ID cards.

Uploaded by

renganathan
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Application for Correction

APPLICATION FOR CORRECTION OF ERROR IN PLASTIC CARD

Name of beneficiary :

Ben. ID No. :

Name of Family Member : 1.

2.

3.

4.

5.

6.

7.

Dispensary :

Nature of Correction :

Correction Required :

Contact Telephone No. :

Encl : Photocopy of Pay Slip & CGHS ID cards


Signature of Applicant

APPLICATION FOR CORRECTION OF ERROR IN PLASTIC CARD Name of beneficiary : Ben. ID No. : Name of Family Member :

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