ESIC Medical Reimbursement Form PDF [Download]

ESI Reimbursement form is used to claim medical expenses when the insured person gets treatment in private hospitals. The Insured person or employer of the insured person should intimate the ESI dispensary before joining the patient in the private hospital and in most of the cases if the private hospital not referred by insurance officer of the particular ESIC dispensary then the claim will get rejected.

In general, we couldn’t get the facilities provided by multi-specialty hospitals in ESI hospitals. In such cases, it is better to give prior intimation to ESI medical officer and take their reference.

Download ESI Medical Reimbursement Claim Form in PDF Format

ESI Reimbursement Form Download | ESIC Medical Reimbursement Claim form

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Required Documents Along With ESI Reimbursement Form

  1. All the medical bills like operation charges, pharmacy charges, room service charges, and ICU charges, etc.
  2. Discharge card from the private hospital where the insured person got treatment.
  3. Emergency Certificate.
  4.  ESIC Pehchan Card of the insured person.
  5.  A letter from the employer side regarding accident cause and request to release the claim amount.
  6. Bank passbook xerox copy of an insured person.

How to Fill ESIC Medical Reimbursement Claim Form

After doing ESI Reimbursement Form download we need to know how to fill this ESIC reimbursement form. This form consists mainly Two parts one part has to be filled by IMP ( Insurance Medical Practitioner ) or IMO ( Insurance Medical Officer ) and the second part has to be filled by hospital authorities where the insured person was treated.

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