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ANNEXURE-III
CERTIFICATE TO BE ISSUED IN LIEU OF IDENTITY CARD UNDER THE NEW HEALTH INSURANCE SCHEME, 2021.
CERTIFICATE
(New Health Insurance Scheme, 2021 ordered in G.O.Ms.No.160, Finance (Salaries) Department Dated: 29-06-2021)
NHIS 2016 ID Card No:
Date of Birth :
Date of Joining :
Date of Retirement:
GPF/TPF/CPS No :
Mobile No :
Certified that Thiru/Tmt./Selvi _____________________ is employed as ____________________ in __________________________________________________________________________________________________ and his/her eligible Family Members as detailed below are eligible for treatments / surgeries covered under the New Health Insurance Scheme, 2021 . The Identity Card under the New Health Insurance Scheme, 2021 is yet to be supplied by the United India Insurance Company Limited, Chennai / Third Party Administrator. This certificate is issued to enable the Employee and their eligible Family Members under the above scheme for availing approved treatments / surgeries in the empanelled hospitals approved by the Insurance Company / Third Party Administrator. The approved hospitals concerned shall provide CASHLESS health care coverage as envisaged under this Scheme:
Details of the Employee and their eligible Family Members under New Health Insurance Scheme, 2021:
Sl.No
Name
Date of Birth
Relationship to the Employee
Marital Status
Employment Status
Whether Physically Challenged/ Intellectually Disabled. **
(Yes/No)
Passport size Photo
1. Self
2.
3.
4.
5.
** Details of Physically Challenged and Intellectually Disabled Children as ordered in para 3 (4) (4) of Annexure-A of the GO to be furnished.
Signature of Drawing and Disbursing Officer in Government Departments / Signature of Pay Drawing Officers in Organisations covered under this Scheme.
Name :
Designation :
Date & Seal :
