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									                                                           Appendix ‘A’

                                                            Application Regn No ________________

                                                           Place of Issue : _______________
                        APPLICATION FORM FOR ENROLMENT INTO
                  EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS)
To,
The Director
Ex-Servicemen Contributory Health Scheme (ECHS)
Regional Centre ____________________

Sir,
      I wish to voluntarily enrol myself as a member of the “Ex-Servicemen Contributory Health
Scheme(ECHS)”, applicable to retired Armed Forces personnel drawing Service/disability Pension or
widows/dependants of Ex-Servicemen drawing Family Pension.

        My personal particulars and details of my family members for whom I wish to avail medical facilities
of the ECHS are noted below for reference:-

PARTICULARS OF PENSIONER

(a) Service No                           _____________________________________
(b) Rank                                 _____________________________________
(c) Name in Full                         _____________________________________
(d) Regt/Corps/Unit                      _____________________________________
(e) Date of Birth                        _____________________________________
(f) Permanent Address                    _____________________________________
                                         _____________________________________
                                         _____________________________________
                                         _____________________________________
(g) Telephone No                         _____________________________________
(h) Date of retirement /discharge        _______________________________ ______
(j) Record Office                        _____________________________________
(k) Pension Payment Order No             _____________________________________
    and particulars
(l) Identification mark(s)               _____________________________________

FAMILY DETAILS
(a) Name of Spouse                      _____________________________________
(b) Date of marriage                    _____________________________________
(c)Date of Birth of Spouse              ______________________________________
(d)Details of dependants and dependant parents as under : -

 Ser     Name                  Date of    Relationship Identification   Marital Employed/     Mention in
 No                            Birth                   Mark(s)          Status Not            Discharge
                                                                                Employed      book
                                                                                *             (Yes/No)
 1
 2
 3
 4
 5
 6

                                                     )
Note : *( Indicate monthly income of dependant parents – It is mandatory to fill this column if dependant
parents are desired to be included in ECHS Coverage.
                                                         2

Details of MRO Payment
                                                   Basic Pension          Rates of Subscription
Bank___________________________                    Upto Rs 3000                  -Rs 1800
Branch__________________________                   Between 3001-6000             -Rs 4800
MRO No_________________________                    Between 6001-10000            -Rs 8400
Dated____________________________                  Between 10001-15000           -Rs 12000
Amount Rs_______________________                   Above 15000                   -Rs 18000
(________________________________                  (Note: Basic Pension excluding DA)
_________________________________)
Attested Affidavit along with one photograph each of self and each dependants is enclosed.

Certified that the particulars given above are correct in all respects. In case it is discovered at any stage by the
ECHS that any of the above particulars given is false, my membership and that of my dependants will be
automatically terminated and MRO money forfeited, without any further reference/relief. I hereby agree to
abide by the Rules prescribed by the ECHS for the above Scheme, as may be amended from time to time.

                                                             Yours faithfully,


Place:                                                       Signature of Ex-Servicemen/Widow applicant
                                                             (Thumb impression of widow
Date:                                                        if illiterate, duly attested by Class I Officer)

                                                  PART II
                                           (FOR USE BY STN HQ’s)
Original documents checked &
photocopy verified and retained
1. PPO                          Yes/No             Certified that particulars given above have been
2. Discharge Book               Yes/No             verified and are correct in all respects.
3. ESM Identity Card            Yes/No
Documents enclosed
4. Affidavit                    Yes/No
5. Passport Size Photo of       Yes/No
   self and all dependents
6. Copy of MRO                  Yes/No                            (Signature of SSO Stn HQ’s)
                                                                  Date : _________________

                                     PART III                                 Enclosures- Tickmark
                         (FOR USE BY REGIONAL CENTRE )                        MRO             Yes/No
CHECK LIST                                                                    Affidavit       Yes/No
                         1. Documents Checked.                                Photograph      Yes/No
                         2. Entry Made in Master Register.                    (of all members)

Date :                                                        (Signature of Supdt)
                                          APPROVED/NOT APPROVED
Particulars of Card issued –
(a) ECHS Card No________________(b) Date of issue_____________

Date:                                                                (Signature of Regional Director)

                                             RECIEPT OF CARD

Dated :                                                                       (Signature of Pensioner)
                                                         3
                                                                                      Affix Passport size
PERSONAL NO              :                                                           Photo of PENSIONER
                                                                                          against light
RANK & NAME              :                                                                background
(in block capitals)
PPO NO                   :

ADDRESS                  :




RECORDS OFFICE :                                                          Signature of Pensioner



   Affix Passport               Affix Passport                Affix Passport                    Affix Passport
     size Photo                   size Photo                    size Photo                        size Photo
    against light                against light                 against light                     against light
   background of                background of                 background of                     background of
    SPOUSE of                      CHILD of                      CHILD of                         CHILD of
     Pensioner                    Pensioner                     Pensioner                         Pensioner


Name                         Name                        Name                             Name
Date of Birth                Date of Birth               Date of Birth                    Date of Birth
                             Employed/ Not Employed      Employed/ Not Employed           Employed/ Not Employed
                             Married/Not Married         Married/Not Married              Married/Not Married


Affix Passport size              Affix Passport               Affix Passport                     Affix Passport
Photo against light                size Photo                   size Photo                         size Photo
  background of                   against light                against light                      against light
     CHILD of                    background of                background of                      background of
     Pensioner                     CHILD of                    FATHER of                          MOTHER of
                                   Pensioner                    Pensioner                          Pensioner


Name                         Name                         Name                               Name
Date of Birth                Date of Birth                Date of Birth                      Date of Birth
Employed/ Not Employed       Employed/ Not Employed
Married/Not Married          Married/Not Married


VERIFIED BY                                                                      ECHS NO
Station Headquarter                                                              (to be given by Regional Headquarter
                                                                                 ECHS)




Signature of verifying Offr at Station          Stamp of verifying Offr at          Date :
Headquarter                                     Station Headquarter

AUTHORISED BY




 Signature of authorising Offr at                Stamp of authorising Offr at Regional
 Regional Headquarter ECHS                       Headquarter ECHS
                                                                      4
     AFFIDAVIT ON Rs. 10/- NON JUDICIAL STAMP PAPER AND ATTESTED BY A MAGISTRATE/NOTARY PUBLIC
                                                              DECLARATION
           I, Service No ____________ Rank ___________ Name _______________________________________________________
of (Unit) ___________________________, solemnly affirm and declare as follows:-
1.          That I am drawing pension vide CDA (P) Pension Payment Order No. _________________________ dated ____________.
2.          That I have the following legal dependant(s) whose photograph(s) is/are affixed on this affidavit:-
            Name                    Relationship        Age         Date of Birth            Part II Order No/Gen Form/AF Order



        Signed photo of Dependent giving name,                              Signed photo of Dependent giving name,
        relationship and Identification mark.                              Relationship and Identification mark.
(Photograph(s) to be pasted on Affidavit & signed across by each applicant. In case of child/minor to be signed by applicant)
3.      That the monthly income of my dependant father and/or dependant mother from all sources is less than Rs 1500/- each.
4.          That my son(s) is/are under the age of 25 year s and is/are not employed and that my daughter(s) are not employed or married.
5.        That I am aware of the fact that my sons are not eligible for the Ex-servicemen Contributory Health Scheme after they attain
25 years of age or get employed at any time before that age.
6.        That I am aware of the fact that my daughter(s) is/are not eligible for the Ex servicemen Contributory Health Scheme after
she/they marry or get employed.
7.       That in case of any change in the status of my dependents (due to death, marriage, employment), I will inform my Regional
Headquarters ECHS at the earliest and will stop use of ECHS facility. I will refund in full the cost of any treatment that a dependent
may have received after he/she became ineligible for the same. I shall be liable for civil/criminal action should I fail to do so.
8.      That I am not a member of any medical scheme funded by the Central Government, Public Sector Undertaking or any other
Government Undertaking.
9.        That, in case I have submitted any fraudulent information or if my ECHS Membership Card is misused/used by any
unauthorized person, my membership will automatically be cancelled and I will forfeit my contribution. I will also be liable for
legal action by the ECHS Organisation. That, I will immediately report the loss of my ECHS Membership Card to Station HQs.


                                                                                                       Signature of Deponent
                                                              V ERIFICATION

I, the deponent above named, do hereby solemnly declare and verify that the contents of the above affidavit are true to the best of my
knowledge and belief, and nothing material has been concealed or suppressed therefrom.
Verified at (Place)………… on this (Date) ………….. day of (Month)………. (Year) ………….


                                                                                                       Signature of Deponent
                                                              ATTESTATION
         Certified that the above statement is declared before me at (Place) ………. on this ………….. day of (Month)……… (Year)
……… by DEPONENT Service No …………Rank ….... Name …………………… who is identified by Name ……………………
S/O (Father’s name of Identifier) ………………….. and witnessed by Name ……………………S/O (Father’s name of first witness) &
Name ………………………. S/O (Father’s name of second witness).
Identified by
Signature of Identifier
(Name in Block Capitals)
(Full Postal Address)
WITNESS

Signature of Witness No 1
1. (Name in Block Capitals)
   (Full Postal Address)

Signature of Witness No 2
2. (Name in Block Capitals)

     (Full Postal Address)                                                           ATTESTED BY
                                                                                     MAGISTRATE/NOTARY PUBLIC
                                                 Application Regn No_______________________


                                 RECEIPT FOR DOCUMENTS
           EX SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS)

 (TO BE PRODUCED BY EX -SERVICEMAN AT THE TIME OF COLLECTION OF MEMBERSHIP CARD)


Received following documents from No____________ Rank_________ Name ____________________
towards application for membership of Ex-Servicemen Contributory Health Scheme (ECHS):-

            1. Application form (duly completed)
            2. Photograph of Pension er and each dependant(s)
            3. Affidavit in original (duly attested)
            4. Copy of MRO (duly receipted)
            5. Photocopy of PPO
            6. Photocopy of Discharge book (except Naval Officers)
            7. Photocopy of ESM Identity Card.




Place:

Date:                                              (Signature of Officer )
                                                   (Adm Comdt/SSO/Officer Station Headquarters)
                              INSTRUCTIONS FOR EX-SERVICEMEN

HOW TO BECOME AN ECHS MEMBER
1.       Eligibility. Only Ex-Servicemen drawing pension/disability pension or widows who are in receipt of
family pension ar e eligible to apply. He/she may approach nearest Station HQs/Military Hospitals at 104
Military Stations and collect the application form for enrolment into the ECHS scheme. The application form
will also be made available through CSDs, Army/Navy/AF Hospitals, and Rajya/Zila Sainik Boards. ECHS
also covers dependants – see conditions stipulated in application form.

2.      Please check the following pages when collecting the application form :-

        (a)     Receipt for handing over of document & instructions for filling up form.

        (b)     Application Form - comprises 3 pages (1 page for pasting photograph).

        (c)     Affidavit format (one page).

        (d)     Four copies of MRO and amount to be deposited as per pension drawn.

COMPLETION OF DOCUMENTATION
3.      Fill in the application form as per de tails required. While filling, care must be taken that name(s) of
dependant(s) tally with service documents / records. All columns and necessary details must be filled;
otherwise the application will be rejected.
4.      An affidavit as per format, duly attested by a Magistrate / Notary Public, will be submitted.
5.      Deposit an MRO as per the contributing amount based on the Basic pension (excluding DA).
6.      Prepare one photocopy each of PPO, Discharge book and ESM identity card.

DEPOSITING APPLICATION FORMS /DOCUMENTS AT DESIGNATED LOCATIONS

7.       Attach the original copies and a photocopy each of your PPO, Discharge book and ESM verified
Identity card with your Application Form. Deposit the Application Form and documents with a Regional
Centre, Station HQ or Army/Navy/AF Hospital. They will initially scrutinise your papers, and also help you if
you have left out any essential details. Before leaving, ensure that the Receiving Officer/JCO/Clerk enters your
particulars & date of receipt of application in his temporary register. Your Application Form & all documents
will thereafter be sent to a designated Station HQ for detailed scrutiny. At Station HQs, the Adm Comdt/SSO
will attest photocopies of essential documents after comparing with originals. Photocopies will be retained.
8.       After 5-6 days, a Receipt bearing an Application Registration No, and your original documents will be
returned to you. You may collect these, either directly from the Station HQs or from the place where you
originally submitted your Application. Please ensure that originals are received intact. Retain your Receipt
carefully as you will be required to produce this when collecting your ECHS Membership Card. In case of any
query/delay you must quote this Registration number to Station HQs.

COLLECTING ECHS MEMBERSHIP CARD & AVAILING TREATMENT

9.     Report to Station HQs with your receipt not earlier than 30 days, but also not later
than 45 days from date of initial submission of Application, and collect your ECHS
Membership Card. You will have to personally sign at the Station HQs a token of having
received your Card. TO AVAIL MEDICAL TREATMENT AT ANY POLYCLINIC / EMPANELLED
HOSPITAL, IT IS MANDATORY FOR PENSIONERS/WIDOWS TO FIRST REPORT                                 TO      NEAREST
POLYCLINIC ALONG WITH ECHS MEMBERSHIP CARD.

								
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