Application Form for Change of Parent of Ex-servicemen Contributory Health Scheme Polyclinic:-

Appendix ‘A’

Polyclinic File ref:_____________________

Date:_____________________

INTIMATION: CHANGE OF PARENT POLYCLINIC

(Separate form to be raised for each card/copy to be sent to concerned Regional Centre)

OIC ECHS Polyclinic
_____________________________________

_____________________________________

_____________________________________(Address of Old Parent Polyclinic)

1. ECHS Card No _____________________________________

2. Name of ECHS beneficiary _____________________________________

3. Relationship with ECHS Member _____________________________________

4. No _____________________________________

5. Rank _____________________________________

6. Name of AFV _____________________________________

7. Old Parent Polyclinic _____________________________________

8. New Parent Polyclinic _____________________________________

9. Date of change of parent Polyclinic _____________________________________

10. Duration from ______________________________ to _________________________________

Declaration by Card Holder

Certified above is true

Date:

(Sign. Of Card Holder)

Remarks of OIC Polyclinic

Verified details as above

Certified above is true

Date:

(Sign. Of OIC Polyclinic)

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Form for Change of ECHS Polyclinic