TRM1
- Document type
- Other
- Dated
- Category
- Documents & Forms
Application for release of exchange
(Item XI of Annexure I to Chapter 8)
Application for release of exchange for medical treatment abroad
- 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 | ||
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: ...................
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: ..................