Niramaya Reimbursement Form

Niramaya Card Number (required)

Name of the Beneficiary (required)

Name of Hitarth Sahayak (required)

Year (required)

Period (required)

Claim Report Upload (required)

Reimbursement for issuing Niramaya Card (required)

Reimbursement Amount(required)

Check mark all that applies for reimbursement (required)

Physiotherapy Speech Therapy OPD (Pathology, diagnostic tests) Dental Preventive Dentistry Medicines Non Surgical / Hospitalization Other

Comments

I confirm that information submitted is accurate.

Hitarth Reimbursement Form