CGHS-CHECKLIST FOR PERMISSION FOR BiPAP, CPAP, 02 CONCENTRATOR (The following format is for CGHS serving employees and pensioners and is based on OM no. S.11011/4/2014-CGHS(P), MOHFW dated 5/3/2014. Similar format for checklist may be used by Departments/ Ministries/Autonomous bodies for their employees)

 

CHECKLIST FOR PERMISSION FOR BiPAP, CPAP, 02 CONCENTRATOR

(The following format is for CGHS serving employees and pensioners and is based on OM no. S.11011/4/2014-CGHS(P), MOHFW dated 5/3/2014. Similar format for checklist may be used by Departments/ Ministries/Autonomous bodies for their employees)

s No	Documents to be enclosed duly indexed	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	Proforma duly signed by treating specialist with stamp
4	Complete basic investigation reports
5	Arterial Blood Gas (ABG) report (in stable state, room air, after discharge from hospital )- NEEDED IN CASE OF 02 CONCENTRATOR & BiLEVEL VENTILATORY SUPPORT SYSTEM
6	Polysomnography (Sleep study report) including all graphs, tracings and tables-NEEDED IN CASE OF BiPAP AND CPAP
7	Undertaking from main card holder on a non judicial stamp paper that he has not claimed reimbursement of the cost of the machine in the last five years in respect of himself/ his dependent in need of the machine and that the machine will be returned to CGHS through CMO l/C, after utility is over.
8	In those cases where permission for a new machine is being sought and cost of old machine has been reimbursed by CGHS more than 5 years back, a condemnation certificate from a technical expert duly countersigned by treating doctor, needs to be enclosed, regarding the irreparable condition of the old machine.
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 pensioner beneficiary has retired from Department——————————–and whether Autonomous body or no (Yes/No).

Contact number of pensioner 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 checklist, needs to befilled mandatorily.

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