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ONLINE WFHS CARD HOLDERS GUIDANCE AND DISCOUNT FEED BACK FORM
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GUIDANCE AND DISCOUNT FEED BACK FORM
GUIDANCE AND DISCOUNT FEED BACK FORM
Contact number for duty hours :1800-425-45535,0487-2445535 mob:8943841498,9645793837
Contact number for off duty hours & holidays :8943841498
Name of card applicant :
WFHS card no :
Card validity :
Email Id :
Name of card holder/ Beneficiary availing Hospital treatment/ Outside centre services :
Empanelled hospital Selected :
District :
Type of treatment Required :
OP
IP
health checkup
Chart for calculating % of discount from empanelled hospital
Treatment required
Allopathy Hospital/clinic
Ayurvedic Hospitals/ clinic
Eye hospital/ clinic
Dental hospital/clinic
Name of hospital/clinic
Registration fee
Op consultation
op procedure medicines
lab tests
scanning
x ray
mammography
ECG EEG
physiotherapy
op procedure
spectacle, lenses
health checkup
IP treatment
ward
room
Exclusions consumables
out sourced Services
implants
medicines
consultation
visiting doctors consultation
op procedure
scanning
lab Tests
any other
radiation
chemotherapy
Whom to contact In hospital/clinic
Total discount % as per agreement :
Empanelled outside center selected :
Type of services required :
Chart for calculating % of discount from empanelled outside hospital centres
Service Required From empanelled centres
Scanning
CT
MRI
ultra sound
Mammo Grapy
x ray
IOPA
OPG
medicines
Lab tests
ECG/EEG
Health Check up
Physio therapy
Hearing aid
Artificial limbs
Spectacle/lenses
Health care/surgical products
Contact person
Total discount % as per agreement :
Treatment /services completed date :
Total treatment /service cost :
Total discount received :
Any suggestion or complaints :
Attach review link
WFHS OFFICE REPORT
Date:
Name of card holder :
Place:
Signature :
File:
Submit
