Shree Lohana Mahaparishad Healthcare Services

Medical Aid Form

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Shree Lohana Mahaparishad Details
Patient Details

Enter the total money earned by all earning members of the patient's family in one year

Enter the total number of family members who have a job or earn money

Upload image from computer

Upload previous month's salary slips/bank statement of all the working members

Medical Condition Details

Enter the diagnosed medical condition of the patient

Indicate the start date of the illness or the date it was diagnosed

Write the name of the doctor treating the patient

Enter the name of the hospital where the patient is receiving treatment

Enter the date when the patient was admitted to the mentioned hospital

Enter the address of the hospital or clinic where the patient is being treated

Enter the total cost required for the patient's treatment

Please upload the treatment cost estimate mentioned above on the hospital's/clinic's official letterhead

Upload Mahajan or LMP Zonal/Regional Office bearer recommendation letter.

Family Details
No.
Family member's name
Age
Occupation
Monthly Income
Relation
Aid Disbursement Details

Name must be of the Hospital or Clinic only. Cheque will not be issued in the name of patient or relative.