Maharshi Patanjali Yog Seva Trust

Application for Medical-aid

Note: Information box left blank will cause rejection of the application.

Name of Applicant (in full)

Date of birth

Age as on date

Caste / Sub-caste

Whether SC/ST/General

Educational qualification

Whether BPL card holder (Yes/No)

if yes, BPL card no:

Applicant's occupation

No. of family members staying with applicant at present

No. of sons:

No. of daughters:

Monthly income of applicant:

Income source:

Describe the disease

How long applicant is suffering from the disease

The root cause of the disease as per doctor's opinion

What is the advice of the doctor

Monthly expenditure of the medicine

Whether medicines are required to be taken for long or permanently (Yes/No)

Whether applicant was operated in the past? (Yes/No)

Whether applicant receives medical aid from other sources. If yes, give details

Addiction, if any:

If yes, give details

Whether criminal/forgery charge framed against you?

If yes, describe the matter

Status of present residence (Owned/Rented/With others)

Whether ready to give service for Trust, when it is required (Yes/No)

Nature of service like to give

Monthly expenditure of Applicant in Rs. (approx.)

Permanent address and contact number, if any

 

Rules, regulation & conditions

• The information furnished by the applicant must be correct. If any information furnished by the applicant is found false or fake, the application will, immediately, be rejected for further proceed.

• If it is found that, after release of Medical-aid, beneficiary furnished false or fake information tactfully, an amount of Medical-aid will, immediately, be recovered, in full and not in a part, from the beneficiary of Medical-aid, with retrospective effect and the same will not be released again, at any cost.

• Submission of application does not mean that the applicant is eligible for Medical aid. But, submission or acceptance of application is an administrative pre-consideration procedure for the same.

• Trust reserves rights to hold or reject or terminate any of applications of Medical aid, without reason and prior intimation.

• Trust reserves rights to increase or decrease or stop an amount of Medical aid once released.

• No claim for any of amounts, with respect to Medical-aid, will be entertained, in the case of reject or hold or terminate of application or aid for the same.

• All beneficiaries of Medical-aid are bound to follow rules, regulations and coditions with respect to Medical -aid, time to time. Breach of any of rules, regulations & conditions will cause termination of Medical aid, with immediate effect.

• In the case of desputing matter, the decision of the president of trust will remain final, bound and acceptable to all the beneficiaries and to all concerned.

Undertaking & Consent letter

All of the above rules, regulations & conditions are read carefully by me with consciousness. I, hereby, deliver my consent and acceptance of all of the above rules, regulations & conditions with respect to Medical-aid.

Signature of the applicant (No need to be signed if forwarded through ONLINE)