Domilicary Treatment Form

THE MERCHANT NAVY OFFICERS' WELFARE FUND (MNOWF)
Udyog Bhavan, 4th Floor, 29, Walchand Hirachand Marg, Ballard Estate, Mumbai 400 001.
Tel.: 91-22 / 2261 9321 Fax : (91-22) 2264 4670 E-mail : mail@mnowf.com Web : www.mnowf.com

For Office Use Only

Inward Date :

Inward No. :

By :

Claim No. :

IN CAPITAL LETTERS - Please fill the Form correctly after reading the instruction : (Over Leaf)

Officer's Name * :

Rank * :

Name of Company * :

Date of Joining * :

Are you permanent employee of the Company? (Yes /No )

Are you on short Term Contract? (Yes /No )

Is your Company remitting donation to MNOWF Corpus on your behalf? (Yes /No )

Ship's Name * :

Date of Signed Off * :

Your MUI Membership No. (If any) * :

On Authorised Leave :

FROM * :

TO * :

(B) Name of the Patient * :

Date of Birth:

Relationship * :

Nature of Illness * :

Is the depenent Patient employed? (If yes)

Name of the Employer * :

Hospitalised

FROM * :

TO * :

Name & Address of the Hospital * :

(Officers' Bank details):

Name of the A/c Holder * :

Account No * :

IFSC Code * :

Name of the Bank * :

Bank Address * :

Name of the Branch * :

Permanent Residence Address * :

Email * :

Tel No * :

Mobile No * :

Pin Code * :

(D)

Sr No.	Name	Amount Claimed	Amount Admissible	Remarks
DETAILS OF MEDICAL EXPENSES
1	Consultation Charges
2	Visit No and Rate
3	Medicines: Given by Doctor Purchase from Outside
4	Investigations
DENTAL EXPENSES
1	Consultation Charges
2	Extraction No and RS
3	Filling, Partial Denture or Treatment of any other nature
4	X-ray

(To be completed by the Attending Doctor)

Diagnosis * :

Duration Illness

FROM * :

TO * :

I hereby declare that the above statement is true to the best of my knowledge and belief

Date * :

Signature of Officer / Wife *

(For Office Use Only.)

Payment Details

Amount Paid :

Checked By: 1 :

Trustee: 1 :

Cheque No :

Checked By: 2 :

Trustee: 2 :

Prepared By :

Date :

Instructions to be followed:

1. Please attached Original Receipts for Consultation, Investigation and Medicines and also Prescription, Investigation reports to enable us to expedite settlement of claim(s). (refer Section "D" & "E").

2. Please ensure that Section "F" is certified / stamped / signed by Medical Practitioner to avoid delay.

3. No claim below Rs. 1000/- will be entertained.

4. Claim Form should be submitted within 90 days after completion of treatment.

5. Separate Claim Form should be submitted for each illness.

6. Officers are requested to submit photo copy of Leave Sanctioned Form, current year Provident Fund statement and relevant page of CDC of last Vessel sign off while filling of Claim Forms.

7. The officer:must ensure that Claim Form should be signed either by the Officer or in his absence by his wife.

8. Verification by the Doctor giving the diagnosis and period of treatment is a MUST for audit purpose.

9. Please intimate if you are receiving medical financial benefits for self and family from any other source(s). Please give details

10. Officer's children up to the age of 25 years are entitled for the Medical reimbursement benefits, subject to the condition that they are unmarried, unemployed and are solely dependent on Officer.

11. Parents, Brothers, Sisters and Relatives of Officer are not eligible for the Medical benefits.

12. Reimbursement of medical expenses will be made by NEFT / RTGS only. Please ensure to submit correct details of your Bank Account.

13. Additional information pertaining to your Medical Claims may be furnish in a separate sheet or to be mentioned in covering letter for sake of clarification.

14. Medical Reimbursement Forms (Hospitalisation Treatment or Domiciliary Treatment) can be obtained from the Funds office on request or you can download Claim Forms from www.mnowf.com

15. All correspondence relating to Medical claims should be sent directly to "The Merchant Navy Officers' Welfare Fund", Udyog Bhavan, 4th Floor, 29 Walchand Hirachand Marg, Ballard Estate, Mumbai - 400 001.

THIS CERTIFICATE TO BE SIGNED BY OFFICER OR HIS WIFE IN CLAIMS OF THEIR CHILDREN

Certificate that my son/daughter

Age

is unmarried,unemployed and solely dependent on me.

Date

Signature
(Officer / Wife)

DOMICILIARY TREATMENT REIMBURSEMENT FORM

(Officers' Bank details):

(To be completed by the Attending Doctor)

(For Office Use Only.)

Payment Details

Instructions to be followed: