Checklist For Issue of Permission for Hearing AID Device for CGHS serving employees and pensioners
CHECKLIST FOR ISSUE OF PERMISSION FOR HEARING AID DEVICE
(The following format is for CGHS serving employees and pensioners based on OM No. S.14025/10/2002/MS, MOHFW dated 26/5/2015. Similar format for checklist may be used by Departments/ Ministries/Autonomous bodies for their employees)
|SNo||Documents to be enclosed duly indexed and numbered||Page Number|
|1||Request letter of CGHS serving / pensioner beneficiary duly forwarded by CMO l/C with despatch number of WC.|
|2||Copy of plastic card of CGHS serving /pensioner beneficiary(ies) (card holder and dependent who need the machine)-duly verified by CMO l/C with stamp|
|3||Computerized referral slip from PARENT WC duly signed by the CGHS doctor.|
|4||Prescription from Govt. ENT Specialist carrying: (a) Pure Tone Audiometry (PTA) report along with diagnosis based on the report (b)Audiometry number (c)Type of Hearing Aid advised as treatment (d)Sign and stamp of Govt. Specialist with name|
|5||PTA report in original carrying (a) PTA report along with diagnosis (b) Audiometry number (c) Countersign and stamp of Govt. Specialist with name|
|6||Undertaking from the main card holder that no reimbursement of Hearing Aid device from CGHS, has been done in the last five years, in respect of himself/ his dependent in need of the Hearing Aid.|
|7||Undertaking by CMO l/C that as per records of the Wellness Centre, no permission for Hearing Aid has been issued to the beneficiary in need of the Hearing Aid, in the last five years.|
|8||In those cases where permission for a new hearing aid device is being sought and cost of old device has been reimbursed by CGHS more than 5 years back, a condemnation certificate from a technical expert duly countersigned by Govt. ENT specialist, needs to be enclosed, regarding the irreparable condition of the old device.|
|9||If representative of pensioner beneficiary is being sent to the Office of Additional Director to collect the permission letter then, the following are needed:
1. authority letter from pensioner beneficiary in favour of the representative
2. Photocopy and original ID card of representative.
3. Original plastic card to be sent with representative
CGHS card is valid till—————————-(dd/mm/yy) as per CGHS database.
The beneficiary has retired from Department——————- and whether Autonomous body or no (Yes/No).
Contact number of beneficiary is ———————-email ID is ———— Forwarded to Additional Director CGHS——————-(city/zone) for necessary action.
Name of CMO l/C /officiating CMO l/C ——————-
Wellness Centre ————————-
Signature and stamp of CMO l/C ——————————-
*Please note-All information as required in the above checklists needs to be filled mandatorily.