TRM 1
(Item XI of Annexure I to Chapter 8)
Application for release of exchange for medical treatment abroad
Documentation:
- 1.
- An estimate of expenses from the overseas doctor/hospital.
- 2.
- Passport of the Patient and attendant/s.
1.
|
Details of the patient
|
(a)
(b)
(c)
(d)
|
Name
Address
Nationality
Passport No. & date
|
(a)
(b)
(c)
(d)
|
|
(e)
|
Passport issued at
|
(e)
|
2.
|
Nature of the aliment
|
3.
|
Expected duration of treatment
|
(i)
(ii)
|
In hospital
Pre/Post hospitalisation
|
(i)
(ii)
|
4.
|
Exchange requirement for the patient
|
(a)
(b)
|
For medical treatment including hospitalisation
For pre/post hospitalisation stay (Living and incidental expenses) |
(a)
(b)
|
5.
|
Exchange requirements for attendant/s (if recommended by the doctor)
|
(a)
(b)
|
Name/s & address/es of the attendant/s
Amount of exchange required and number of days
|
(a)
(b)
|
6.
|
Any other relevant information
|
|
DECLARATION
I hereby declare that the statements made above are true to the best of may knowledge and belied.
I also declare that I/the patient have/has not submitted and will not submit any application for the same purpose to any other branch/office of any authorised dealer in foreign exchange in India.
I further undertake to submit within a period of 30 days of amy/the patients return to India, a statement of account of the expenses incurred abroad, duly supported by bills, where necessary, together with a certificate from the attending physician/surgeon that I/the patient have/has undergone the treatment.
..........................................
(Signature of patient/applicant)
Place: .....................
Date: ...................
Certificate from the Treating Physician/Surgeon
1.
|
Brief description of the ailment
| |
2.
|
Specific reasons for which a visit to a specialist/ institution in a foreign country is necessary
| |
3.
|
Estimated period of treatment abroad
| |
|
I certify that I have satisfied myself that the ailment from which the patient is suffering is of such a nature that treatment abroad is necessary.
Signature______________________________________
Name of the applicant____________________________
Registration No._________________________________
Address:_______________________________________
Place: ....................
Date: ..................