Assam Atal Amrit Abhiyan Application Form PDF

Assam Atal Amrit Abhiyan Application Form

This is the application form for Statewide Health Assurance Scheme issued by the Health & Family Welfare
Government of Assam for all BPL families and APL families in the state having annual family income up to Rs. 5 lakh and it can download from the link given below. The Filled in the application form is to be submitted, by hand or by post, to the Office of the Joint Director of Health Services of the concerned district.

Details to be Mention in Atal Amrit Abhiyan Application Form

• Patients Details
• Annual Income
• Address
• Disease for which Treatment is required
• Name of Hospital where the treatment received
• The total cost incurred in the treatment
• Any other Information

Documents Required

• Photograph of the Patient (Attested by Doctor)
• Annual Income Certificate issued by Circle Officer (Attested copy of the certificate to be enclosed along with the application)
• Attested copy of the Voter ID or Voter ID of Parent
• Attested copy of the Referral Certificate/ Discharge certificate & Prescription from the hospital
• Original copy of the Bills attested by the treating hospital (Only empanelled hospital under Assam Arogya Nidhi)

The Salient Features of the Scheme

1) The Scheme is being implemented through one Implementation Support Agency (ISA) named Medi Assist Insurance TPA Pvt. Ltd., selected and engaged for the purpose.

2) Scheme will be open for all BPL families and APL families in the state having annual family income upto Rs. 5 lakh. Families of government employees are not eligible under the Scheme.

3) Each individual adult member of the eligible families will be enrolled for the purpose through the ISA and will be issued with a laminated ID card having a unique identification number to facilitate cashless treatment facility at the empanelled hospitals. Children below 18 years of age will be enrolled with the head of the family.

4) The Scheme will be free for BPL families and a nominal amount of Rs. 100/- will be collected from each member of the APL family as enrolment fees annually.

5) The Scheme will provide inpatient treatment facility at the empanelled hospitals (Private and Public) up to a maximum limit of Rs. 2.00 lakh per individual member per annum within and outside the State of Assam covering 438 procedures for the following diseases:

 

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