KASHMIRI MEDICAL EMERGENCY & CHARITABLE TRUST

(REGD. SINCE 2010 - Registration no: 3959/2010-11)

APPLICATION FORM

( Application of Request For Financial Medical Aid)


    PATIENT DATA


    MONTHY INCOME(OF PATIENT)


    FAMILY DATA


    PATIENT ILLNESS / TREATMENT DETAILS


    FINANCIAL ASSISTANCE DETAILS

    A. FOR HOSPITALISATION / EMERGENCY TREATMENT PATIENTS


    FOR MEDICAL SUSTENANCE CASES ( PATIENTS REQUIRING MONTHLY EXPESES ON MEDICATION)


    MEDICAL REIMBURSMENT DETAILS


    MEDICAL REIMBURSMENT DETAILS

    ( SHOULD BE PREFERABLY A FAMILY MEMBER WHO CAN CO-ORDINATE WITH KMECT ON DAY TO DAY BASIS)

    TERMS & CONDITIONS

    Kashmiri Medical Emergency & Charitable Trust, also referred to as KMECT, terms and conditions for the services provided by it to the recipients of these services, will observe following terms & conditions strictly:

    *The patient / his family will read these terms & conditions & confirm the understanding & thus acceptance of the same by signing this form.
    *The information provided by the Patient / Applicant should be correct / true.
    *The service rendered by or through Trust, has no legal binding nor the advice/service provided, can be taken for legal scrutiny.
    *The Trust does not hold any responsibility for the consequences of the services/advice provided by the Trust/doctors panel of Trust or wrong treatment by the hospital.
    *In case of any wrong declaration or hiding of any facts / information pertaining to the patient/case, the Trust reserves the rights to withdraw support/funding & recover the funds released prior to withdrawal.
    *In case of re-imbursement from any of the sources, the patient / his family shall reimburse/return the amount funded to KMECT
    *In case of receipt of donations directly by the patient / his family, they shall reimburse/return the amount to KMECT to the extent of the funds paid by KMECT to the patient / his family.
    *The Patient details will be used by KMECT for the purpose of collection of funds & disclosing to any government authority/ agency being a registered Trust. The details will be put on net / published in the media by KMECT. The patient / his family will have no objection to the same.
    *The patient or his family/friends will not release any advertisement on net, news paper and/ or publicize in any media directly for funds. In case of huge requirement of funds & if due to any extreme urgency, the same is done by them, they will do so after consulting KMECT & also mention in the published ad/appeal “The patient treatment is supported by Kashmiri Medical Emergency & Charitable Trust – the contributions may directly be sent to them”. The bank details of KMECT & not that of patient should be provided in the appeal.
    *In case the patient / his family/friends release the advertise for direct funding in their/patient’s name, KMECT is free to withdraw the support & claim refund from the patient / his family.

    L. Please Note;
    i. Documents mentioned under clause 9 are a must to be submitted.
    ii. In case requested by KMECT, you will submit the Bills in support of expenditure incurred so far needs to be provided for us to decide on the extent of future support by KMECT.
    iii. In case requested by KMECT, you will submit the Salary / income certificate.
    iv. KMECT in no case reimburse the expenses already incurred by family.
    v. Subject to approval of case by BOT of KMECT, cheques are paid directly to the hospital or chemist account and not to patient or family account.
    vi. Any patient suffering from life consuming disease where chances of survival are less than 50 %, KMECT may consider providing pain management treatment. Amount to be decided by BOT/ Doctor on Panel and may vary from case to case.
    vii. In case KMECT requested you to submit any other document, considered by KMECT Team important to consider & process the case, you will have to submit the same immediately on request..

    Declaration By Patient / Relatives
    I/We hereby declare that the information given by me/us above is true to the best of my knowledge.
    Presently I/we am not in a position to arrange funds for the medical emergency stated above.
    I / we have read the above terms & conditions and the same are understood by me/us.
    I/We confirm the acceptance of these terms & conditions.
    (The nomenclature "we" includes the patient & his family, friends, relations who are coordinating with KMECT)