2. Artemis Hospital Gurgaon Dwarka, Delhi. 5. Balaji Action Medical Institute, Paschim Vihar, New Delhi. 8. PSRI Hospital, Sheikh Sarai, New Delhi

Transcription

1 PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ANY ONE OF THE FOLLOWING APPROVED HOSPITALS FOR EXECUTIVE CHECK-UP (For employees & their spouses who are 45 years & above only) I am willing to avail of the Executive Health Check-up for self and spouse as per details given below: Name. Designation Emp. No.... Division.... DOB/Age... Status : Reg./ Dep. Opted RITES Medical Facility (Yes / No) Intercom No Mobile Spouse Name (Mr./Mrs.)... DOB/ Age Medanta, The Medicity, Gurgaon 4. Primus Super Specialty Hospital, Chankya Puri, New Delhi 7. Deepak Memorial Hospital Vikas Marg, Delhi 10. Rockland Hospitals Qutab Area, New Delhi Manesar, Gurgaon Dwarka, New Delhi 13. Escorts Heart Institute, Okhla, New Delhi 16. Moolchand Hospital, Lajpat Nagar, New Delhi 19. Fortis Hospital Sector 62, Noida Vasant Kunj, New Delhi Neelam Chowk, Faridabad Karol Bagh, New Delhi Shalimar Bagh, Delhi 2. Artemis Hospital Gurgaon Dwarka, Delhi 5. Balaji Action Medical Institute, Paschim Vihar, New Delhi 8. PSRI Hospital, Sheikh Sarai, New Delhi 11 Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 14. Batra Hospital, Tuglakabad, New Delhi 17. Alchemist Hospital Gurgaon 3. Columbia Asia Hospital Palam Vihar, Gurgaon Ghaziabad 6. Kailash Hospital Sector 27 Sector 11, Gr. Noida 9. National Heart Institute, East of Kailash, New Delhi 12. Metro Hospital & Heart Institute Sector 11, Noida Preet Vihar, Delhi Palam Vihar, Gurgaon 15. Dr. B. L. Kapur Mem. Hospital, Pusa Road, New Delhi 18. Paras Hospital, Sushant Lok, Gurgaon ( ) Please tick against the hospital & location. Signature... Date:... Signature of the Controlling Officer with Designation

2 PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY OF THE FOLLOWING HOSPITALS (For employees & their spouses who are 45 years & above) I am willing to avail of the Health Check-up package for self and / or for my spouse (Mr./Smt (Date of Birth....) as per my choice given below:- ESCORTS HOSPITAL Okhla APOLLO HOSPITAL Sarita Vihar NATIONAL HEART INSTITUTE East of Kailash Executive Check-up Executive Check-up Executive Check-up For males For males For males Rs.2800/- Rs.3250/- Rs. 3200/- BATRA HOSPITAL Mehrauli Badarpur Road TIRATH RAM HOSPITAL Rajpur Road FORTIS HOSPITAL Vasant Kunj / Noida / Faridabad Karol Bagh / Shalimar Bagh. Executive Check-up Executive Check-up Executive Check-up Rs.2100/- Rs.2175/- MEDANTA THE MEDICITY Sector-38, Gurgaon. COLUMBIA ASIA Palam Vihar, Gurgaon. For males Rs.3250/- ALCHEMIST HOSPITAL Sector -53, Gurgaon Comprehensive Check up Rs.3500/- For males &females DR.B.L. KAPUR HOSPITAL Pusa Road, New Delhi Moolchand Hospital Lajpat Nagar, New Delhi (For Rs. 3000/- males/females) Kailash Hospital & Heart Institute H-33, Sector-27, Noida (for Males/Females) Asian Institute of Medical Sciences Sector-21 A,Faridabad (for Males/Females) () St. Stephen s Hospital, Tis Hazari, Delhi Rs. 3000/- Rs. 2450/- (for Males / Females) Rs. 3200/- Paras Hospitals C-1, Sushant Lok, Sector-43, Gurgaon Rs.4000/- (for Males/Females) Rs. 3150/- Park Hospital Outer Ring Road,New Delhi / Malviya Nagar,New Delhi / South City-II,Gurgaon / Sector-10,Faridabad (for Males/Females) Rs. 3000/- ( ) Please tick against the package of the hospital & location. Name. Designation Emp. No... Division. DOB Status : Regular/Deputation, Whether opted RITES Medical Facility (Yes/No) Intercom No.. Mobile / Landline No Signature... Dated:. Signature of the Controlling Officer with Designation

3 List of investigation & Clinical tests at the hospitals/clinics for Health Check-up programme Escorts Hospital/Okhla Fortis Hospital Vasant Kunj/Noida/Faridabad/ Karol Bagh/Shalimar Bagh. Comprehensive Check-up Doctors Consultations & full medical exam. Blood Tests Complete haemogram (Hb, TLC,DLC, ESR, Haematocrit, Peripheral Smear) Blood Group (ABO, RH), Blood Sugar (Fasting & Post Prandial), Blood Urea, Serum Uric acid, Serum Creatinine, Serum Cholesterol, Lipid Profile Urine Examination, X-Ray Chest PA, ECG Exercise Stress Test (TMT), Stress Screening by Psychologist, Eye Examination, Post Checkup consultation, Gynecologist Consultation & Pap Smear Test, () Tests in Comprehensive checkup Plus Stool RE Pulmonary Function Test (Routine) Liver Function Test (includes SGOT) Ultra Sound whole abdomen ALCHEMIST HOSPITAL Sector -53, Gurgaon Comprehensive Checkup Haemogram: Haemoglobin, MCHC, MCV, MCH, Different count, Platelet count, PCV, Total WBC, Peripheral smear Biochemical Parameters: Blood Sugar (F&PP), Uric Acid, Urea creatininr, NA, K, Ca, PO-4, Lipid Profile, Total cholesterol : HDL Cholesterol, Triglycerides screening, Total Cholesterol, HDL Ratio Fiver Function Test : Total Protein, Globulin, SGPT, GGTP, Albumin, A/G Ratio, Alkaline Phosphates General Tests : Complete Urine analysis, ECG (Resting), Ultra Sound abdomen screening, X-Ray Chest, TMT/Echo, PFT, Consult with internal Medicine, Gynecologist for female, Consult with Surgeon. Apollo Hospital Sarita Vihar Health Cheq Haemogram Haemoglobin MCHC, MCV, MCH Differential count Platelet count PCV, Total WBC Peripheral smear Biochemical Parameters Blood Sugar (Fasting &PP) Uric Acid, Urea Creatinine Lipid Profile, Total Cholesterol HDL Cholesterol Triglycerides screening, Total Cholesterol/HDL Ratio Liver Function Tests Total Protein, Globulin, SGPT, GGTP, Albumin, A/G Ratio, Alkaline Phosphatase General Tests VDRL, Complete Urine analysis ECG (Resting) Ultrasound abdomen screening Blood Grouping & RH-typing Faeces examination X-Ray Chest Clinical examination, Medical Summary & advice by Sr. Consul-tant, Internal Medicine, Genital/Rectal examination by Sr. General Surgeon/Gynecologist. Executive Health Cheq Full Package of Health Chaq mentioned above Plus Pulmanary Function Test (PFT) Tread Mill (TMT) National Heart Institute East of Kailash Doctors Consultation & Full medical examination Blood Tests - Complete Haemogram (Hb, TLC, DLC, ESR, Haematocrit & Peripheral Smear) Blood Group (ABO, Rh) Blood Sugar (Fasting & PP) Blood Urea Serum Uric acid Serum Creatinine Lipid Profile Urine Examination X-Ray Chest PA ECG Exercise Stress Test (TMT) Liver Function Test Pulmonary Frnction Test / Thyroid - profile Ultra Sound Whole Abdomen Basic Eye Examination Basic Dental Check-up Gynecologist Consultation & PAP Smear Test Post Check up Consultation. Moolchand Hospital Lajpat Nagar, New Delhi Blood Grouping & Rh type, DLC, ESR, Haemoglobin MCV/MCH/MCHC, Packed Cell Volume, Platelet count, Peripheral count, RBC count, RDW, TLC Biochemistry Blood Sugar F & PP, Blood Urea, S.Creatinine, Uric Acid, Liver Function Test Albumin/Globulin Ratio, Alkaline Phosphatase, Bilirubin Total/Direct/Indirect, S. Calcium & S. Phosphorus S. Protein/Albumin/Globulin, SGOT/SGPT/SGGTP, Lipid Profile, PAP Smear (For f.males) Stool-Routine, Urine Analysis ECG, Ultra Sound (L & U Abdomen), X-Ray PA. Consultation Medicine, Gynae (for females) Opthalmology & Dental Comprehensive Checkup Plus TMT & PFT (basic Spirometry)

4 PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY OF THE FOLLOWING HOSPITALS I am willing to avail of the Health Check-up package for self and / or for my spouse (Mr./Smt (Date of Birth....) as per my choice given below:- ESCORTS HOSPITAL, Okhla APOLLO HOSPITAL Sarita Vihar NATIONAL HEART INSTITUTE East of Kailash Comprehensive Checkup Health Cheq. Executive Health Check For males Rs.1850/- Rs.2100/- Rs.2100/- For males Rs.2800/- Executive Check-up Executive Cheq For males BATRA HOSPITAL Mehrauli Badarpur Road Rs.3250/- Rs. 3200/- TIRATH RAM HOSPITAL Rajpur Road FORTIS HOSPITAL Vasant Kunj / Noida / Faridabad Karol Bagh / Shalimar Bagh. Comprehensive Checkup Executive Check-up Comprehensive Checkup Rs.1600/- Rs.1500/- For males Rs. 1850/- Rs.2100/- Executive Health Check Heart Check Executive Check-up For males Rs.2100/- Rs.2175/- Rs.3250/- MEDANTA THE MEDICITY Sector-38, Gurgaon. COLUMBIA ASIA Palam Vihar, Gurgaon. ALCHEMIST HOSPITAL Sector -53, Gurgaon Comprehensive Checkup Comprehensive Checkup Comprehensive Checkup For Rs.2650/- Rs.2100/- males Rs.3500/- For females Comprehensive Checkup DR.B.L. KAPUR HOSPITAL Pusa Road, New Delhi Rs. 2300/- Rs. 3000/- Comprehensive Checkup Moolchand Hospital Lajpat Nagar, New Delhi Rs.2300/- & Rs.2600/- Rs. 3000/- ( ) Please tick against the package of the hospital & location. Name. Designation. Emp. No.. Division..... DOB.....Status : Regular/Deputation Whether opted RITES Medical Facility (Yes / No) Intercom No Signature... Mobile /Landline No Dated:. Signature of the Controlling Officer with Designation

5 Batra Hospital Mehrauli Badarpur Road. General Health Check-up Tirath Ram Shah Rajpur Road General Health Check Madanta The Medicity Sector-38, Gurgaon. Comprehensive health Checkup Clinical Examination by Sr. Consultant, internal medicine. Eye examination by Sr. Consultant Ophthalmology Haemogram, Haemoglobin Different Count - Platelet Count - WBC - Peripheral Smear - MCHC - MCV - PCV - MCH Diabetic & Renal Parameters - Blood Sugar (F&PP) - Uric Acid - Urea - Creatinine - Urinary Micro Albuminuia Lipid Prifile Total Cholelsterol HDL, LDL - Triglycerides, Glycoslated Hb Liver Function Tests - Total Proteins - Albmin - Globulin - A/G Ratio - SGOT, - SGPT - Alkaline Phosphatase - SGGT Thyroid Function Tests - F-T3, F-T4, & F-TSH General Tests - Urine & Stool routine & ME - (Resting ) ECG - Blood Grouping & RH Typing - X-Ray Chest (PA view) - PEFR - Gynecologist consultation - Final Assessment & report by Sr. Consultant, Internal Medicine Haemogram - Haemoglobin - Different Count - Platelet Count - PCV - Total WBC - Peripheral Smear - History & full General Examination Gynae check-up by Gynecologist (Women) Sr. Surgeon (Men) - MCHC - MCV - MCH Diabetic & Renal Parameters - Blood Sugar (F&PP) - Uric Acid - Urea - Micro Albuminuia - Creatinine Lipid Prifile (Including SERUM Cholesterol, HDL, LDL, Cholesterol, Triglycerides) Liver Function Tests - Total Proteins - Albmin - Globulin - A/G Ratio - SGOT, SGPT, SGGT - Alkaline Phosphatase General Tests - Complete Urine & Stool routine analysis - ECG (Resting ) - Ultrasound of whole abdomen - Blood Grouping & RH Typing - X-Ray Chest (PA view) Executive Health Check (General Health check) plus - HBSAG - TMT (Treadmill exercise Test) Complete Haemogram, ESR, Haematocrit, Blood Group (ABO, RH) Blood Group (F & PP), Blood Urea, Serum Uric Acid, Serum Creatinine, Serum Cholestrol, Lipid Profile, Stool routine examination, Urine examination, X-Ray Chest, ECG, Ultra Sound (whole abdomen), Stress screening by psychologist, Eye examination, Post examination consultation, Gynecologist conbsultation & Pap smear test, (Comprehensive Checkup) plus PFT (Routine), LFT (includes SGOT), Exercise Stress Test (TMT) Columbia Asia Block-F, Palam Vihar, Gurgaon Comprehensive Checkup Haemogram Haemoglobin, MCHC, MCV, MCH, Different Count, Platelet Count, PCV, Total WBC, Peripheral Smear Biological Parameters Blood Sugar (F & PP), Uric Acid, Uric Creatinime Lipid Profile Total Cholesterol, HDL Cholesterol, Triglycerides Screening, HDL Ratio Liver Function Test Total Protein, Globulin, SGPT, GGTP, Albumin, A/G Ratio, Alkaline Phosphates General Tests VDRL, Complete Urine analysis, ECG (Rating), Ultra Sound abdomen screening, Blood Grouping & RH typing, Faeces examination, X-Ray Chest, Consult with internal medicine, Consult with Gynecologist for female, Consult with Surgeon. Executive Health Check All tests of Batra General Health Check PLUS Ultra Sound L&U abdomen, Cardiac Function Test TMT & ECG Heart Check All tests of Executive Health Check PLUS Echocardiography & Cardiac Check up by Cardiologist Tests in Comprehensive checkup Plus TMT PFT

6 RITES LIMITED Welfare Section PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT Case No... Date:... NAME: Design. /Division. Emp. No: Place of Posting. Patient Name...Relationship Illness..... Name & location of Hospital Estimate with Breakup given by hospital... Payment of Advance 80% of Rs. Sanction may kindly be accorded for medical advance of Rs... Payment may be released in favour of by a crossed cheque. Excess amount if any paid beyond the admissibility would be adjusted as per existing rules. Dependency checked from official records SO (Welfare) JGM (Welfare & Protocol) GGM (Admn) GM (FE)

7 RITES LIMITED Welfare Section PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT Case No... Date:... NAME: Design. /Division. Emp. No: Place of Posting. Patient Name...Relationship Illness..... Name & location of Hospital Estimate with Breakup given by hospital... Payment of Advance 80% of Rs. Sanction may kindly be accorded for medical advance of Rs... Payment may be released in favour of by a crossed cheque. Excess amount if any paid beyond the admissibility would be adjusted as per existing rules. Dependency checked from official records AM(P)/ (Welfare) JGM (Welfare & Protocol) GGM (Admn) GM (FE)

8 RITES LIMITED Welfare Section PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT Case No... Date:... NAME: Design. /Division. Emp. No: Place of Posting. Patient Name...Relationship Illness..... Name & location of Hospital Estimate with Breakup given by hospital... Payment of Advance 80% of Rs. Sanction may kindly be accorded for medical advance of Rs... Payment may be released in favour of by a crossed cheque. Excess amount if any paid beyond the admissibility would be adjusted as per existing rules. Dependency checked from official records AM/P (Welfare) JGM (Welfare & Protocol) GGM (Admn) GM (FE)

9 PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY OF THE FOLLOWING HOSPITALS (For employees & their spouses who are 45 years & above) I am willing to avail of the Health Check-up package for self and / or for my spouse (Mr./Smt (Date of Birth....) as per my choice given below:- 1. ESCORTS Heart Institute Okhla Road, New Delhi 2. Indraprastha Apollo Hospital Sarita Vihar, Mathura Road, New Delhi 3. National Heart Institute 49-50, Community Centre, East Kailash, N. Delhi 4. Batra Hospital 1, Tuglakabad Industrial Area M.B. Road, New Delhi 5. Park Hospital 1. Meera Enclave, Outer Ring Road, N. Delhi 2. Malviya Nagar, New Delhi 3. South City-II, Gurgaon 4. Sector-10, Faridabad 6. Fortis Hospital 1. B-22, Sector-62, Noida 2. Sec-B, Pkt-1,Aruna Asafali Mrg,Vasant Kunj, 3. Neelam Bata Road, Faridabad, 4. WEA, Karol Bagh, New Delhi 5. A-Block,Shalimar Bagh, New Delhi 7. Medanta, the Medicity Sector-38, Gurgaon 8. Columbia Asia Block-F, Palam Vihar, Gurgaon 9. Alchemist Hospital Sec. 53, Saraswati Kunj, DLF Golf Course Road, Gurn 10. Dr. B.L. Kapur Memorial Hospital Pusa Road, New Delhi 11. Moolchand Hospital Lajpat Nagar, New Delhi 12. St. Stephens Hospital Tis Hazari, Delhi. 13. Kailash Hospital H-33, Sector-27, Noida 14. Asian Institute of Medical Science Sector-21A, Faridabad Paras Hospital C-1, Sushant Lok, Sector-43, Gurgaon 16. TIRATH RAM HOSPITAL Rajpur Road, New Delhi ( ) Please tick against the hospital & location. Name. Designation Emp. No... Division. DOB Status : Regular/Deputation, Whether opted RITES Medical Facility (Yes/No) Intercom No.. Mobile / Landline No Signature... Dated:. Signature of the Controlling Officer with Designation

10 PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY OF THE FOLLOWING HOSPITALS (For employees & their spouses who are 45 years & above) I am willing to avail of the Health Check-up package for self and / or for my spouse (Mr./Smt (Date of Birth....) as per my choice given below:- ESCORTS HOSPITAL Okhla APOLLO HOSPITAL Sarita Vihar NATIONAL HEART INSTITUTE East of Kailash Executive Check-up Executive Check-up Executive Check-up For males For males For males Rs.2800/- Rs.3250/- Rs. 3200/- BATRA HOSPITAL Mehrauli Badarpur Road TIRATH RAM HOSPITAL Rajpur Road FORTIS HOSPITAL Vasant Kunj / Noida / Faridabad Karol Bagh / Shalimar Bagh. Executive Check-up Executive Check-up Executive Check-up Rs.2100/- Rs.2175/- MEDANTA THE MEDICITY Sector-38, Gurgaon. COLUMBIA ASIA Palam Vihar, Gurgaon. For males Rs.3250/- ALCHEMIST HOSPITAL Sector -53, Gurgaon Comprehensive Check up Rs.3500/- For males &females DR.B.L. KAPUR HOSPITAL Pusa Road, New Delhi Moolchand Hospital Lajpat Nagar, New Delhi (For Rs. 3000/- males/females) Kailash Hospital & Heart Institute H-33, Sector-27, Noida (for Males/Females) Asian Institute of Medical Sciences Sector-21 A,Faridabad (for Males/Females) () St. Stephen s Hospital, Tis Hazari, Delhi Rs. 3000/- Rs. 2450/- (for Males / Females) Rs. 3200/- Paras Hospitals C-1, Sushant Lok, Sector-43, Gurgaon Rs.4000/- (for Males/Females) Rs. 3150/- Park Hospital Outer Ring Road,New Delhi / Malviya Nagar,New Delhi / South City-II,Gurgaon / Sector-10,Faridabad (for Males/Females) Rs. 3000/- ( ) Please tick against the package of the hospital & location. Name. Designation Emp. No... Division. DOB Status : Regular/Deputation, Whether opted RITES Medical Facility (Yes/No) Intercom No.. Mobile / Landline No Signature... Dated:. Signature of the Controlling Officer with Designation

11 List of investigation & Clinical tests at the hospitals/clinics for Health Check-up programme Escorts Hospital/Okhla Fortis Hospital Vasant Kunj/Noida/Faridabad/ Karol Bagh/Shalimar Bagh. Comprehensive Check-up Doctors Consultations & full medical exam. Blood Tests Complete haemogram (Hb, TLC,DLC, ESR, Haematocrit, Peripheral Smear) Blood Group (ABO, RH), Blood Sugar (Fasting & Post Prandial), Blood Urea, Serum Uric acid, Serum Creatinine, Serum Cholesterol, Lipid Profile Urine Examination, X-Ray Chest PA, ECG Exercise Stress Test (TMT), Stress Screening by Psychologist, Eye Examination, Post Checkup consultation, Gynecologist Consultation & Pap Smear Test, () Tests in Comprehensive checkup Plus Stool RE Pulmonary Function Test (Routine) Liver Function Test (includes SGOT) Ultra Sound whole abdomen ALCHEMIST HOSPITAL Sector -53, Gurgaon Comprehensive Checkup Haemogram: Haemoglobin, MCHC, MCV, MCH, Different count, Platelet count, PCV, Total WBC, Peripheral smear Biochemical Parameters: Blood Sugar (F&PP), Uric Acid, Urea creatininr, NA, K, Ca, PO-4, Lipid Profile, Total cholesterol : HDL Cholesterol, Triglycerides screening, Total Cholesterol, HDL Ratio Fiver Function Test : Total Protein, Globulin, SGPT, GGTP, Albumin, A/G Ratio, Alkaline Phosphates General Tests : Complete Urine analysis, ECG (Resting), Ultra Sound abdomen screening, X-Ray Chest, TMT/Echo, PFT, Consult with internal Medicine, Gynecologist for female, Consult with Surgeon. Apollo Hospital Sarita Vihar Health Cheq Haemogram Haemoglobin MCHC, MCV, MCH Differential count Platelet count PCV, Total WBC Peripheral smear Biochemical Parameters Blood Sugar (Fasting &PP) Uric Acid, Urea Creatinine Lipid Profile, Total Cholesterol HDL Cholesterol Triglycerides screening, Total Cholesterol/HDL Ratio Liver Function Tests Total Protein, Globulin, SGPT, GGTP, Albumin, A/G Ratio, Alkaline Phosphatase General Tests VDRL, Complete Urine analysis ECG (Resting) Ultrasound abdomen screening Blood Grouping & RH-typing Faeces examination X-Ray Chest Clinical examination, Medical Summary & advice by Sr. Consul-tant, Internal Medicine, Genital/Rectal examination by Sr. General Surgeon/Gynecologist. Executive Health Cheq Full Package of Health Chaq mentioned above Plus Pulmanary Function Test (PFT) Tread Mill (TMT) National Heart Institute East of Kailash Doctors Consultation & Full medical examination Blood Tests - Complete Haemogram (Hb, TLC, DLC, ESR, Haematocrit & Peripheral Smear) Blood Group (ABO, Rh) Blood Sugar (Fasting & PP) Blood Urea Serum Uric acid Serum Creatinine Lipid Profile Urine Examination X-Ray Chest PA ECG Exercise Stress Test (TMT) Liver Function Test Pulmonary Frnction Test / Thyroid - profile Ultra Sound Whole Abdomen Basic Eye Examination Basic Dental Check-up Gynecologist Consultation & PAP Smear Test Post Check up Consultation. Moolchand Hospital Lajpat Nagar, New Delhi Blood Grouping & Rh type, DLC, ESR, Haemoglobin MCV/MCH/MCHC, Packed Cell Volume, Platelet count, Peripheral count, RBC count, RDW, TLC Biochemistry Blood Sugar F & PP, Blood Urea, S.Creatinine, Uric Acid, Liver Function Test Albumin/Globulin Ratio, Alkaline Phosphatase, Bilirubin Total/Direct/Indirect, S. Calcium & S. Phosphorus S. Protein/Albumin/Globulin, SGOT/SGPT/SGGTP, Lipid Profile, PAP Smear (For f.males) Stool-Routine, Urine Analysis ECG, Ultra Sound (L & U Abdomen), X-Ray PA. Consultation Medicine, Gynae (for females) Opthalmology & Dental Comprehensive Checkup Plus TMT & PFT (basic Spirometry)

12 PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY OF THE FOLLOWING HOSPITALS I am willing to avail of the Health Check-up package for self and / or for my spouse (Mr./Smt (Date of Birth....) as per my choice given below:- ESCORTS HOSPITAL, Okhla APOLLO HOSPITAL Sarita Vihar NATIONAL HEART INSTITUTE East of Kailash Comprehensive Checkup Health Cheq. Executive Health Check For males Rs.1850/- Rs.2100/- Rs.2100/- For males Rs.2800/- Executive Check-up Executive Cheq For males BATRA HOSPITAL Mehrauli Badarpur Road Rs.3250/- Rs. 3200/- TIRATH RAM HOSPITAL Rajpur Road FORTIS HOSPITAL Vasant Kunj / Noida / Faridabad Karol Bagh / Shalimar Bagh. Comprehensive Checkup Executive Check-up Comprehensive Checkup Rs.1600/- Rs.1500/- For males Rs. 1850/- Rs.2100/- Executive Health Check Heart Check Executive Check-up For males Rs.2100/- Rs.2175/- Rs.3250/- MEDANTA THE MEDICITY Sector-38, Gurgaon. COLUMBIA ASIA Palam Vihar, Gurgaon. ALCHEMIST HOSPITAL Sector -53, Gurgaon Comprehensive Checkup Comprehensive Checkup Comprehensive Checkup For Rs.2650/- Rs.2100/- males Rs.3500/- For females Comprehensive Checkup DR.B.L. KAPUR HOSPITAL Pusa Road, New Delhi Rs. 2300/- Rs. 3000/- Comprehensive Checkup Moolchand Hospital Lajpat Nagar, New Delhi Rs.2300/- & Rs.2600/- Rs. 3000/- ( ) Please tick against the package of the hospital & location. Name. Designation. Emp. No.. Division..... DOB.....Status : Regular/Deputation Whether opted RITES Medical Facility (Yes / No) Intercom No Signature... Mobile /Landline No Dated:. Signature of the Controlling Officer with Designation

13 Batra Hospital Mehrauli Badarpur Road. General Health Check-up Tirath Ram Shah Rajpur Road General Health Check Madanta The Medicity Sector-38, Gurgaon. Comprehensive health Checkup Clinical Examination by Sr. Consultant, internal medicine. Eye examination by Sr. Consultant Ophthalmology Haemogram, Haemoglobin Different Count - Platelet Count - WBC - Peripheral Smear - MCHC - MCV - PCV - MCH Diabetic & Renal Parameters - Blood Sugar (F&PP) - Uric Acid - Urea - Creatinine - Urinary Micro Albuminuia Lipid Prifile Total Cholelsterol HDL, LDL - Triglycerides, Glycoslated Hb Liver Function Tests - Total Proteins - Albmin - Globulin - A/G Ratio - SGOT, - SGPT - Alkaline Phosphatase - SGGT Thyroid Function Tests - F-T3, F-T4, & F-TSH General Tests - Urine & Stool routine & ME - (Resting ) ECG - Blood Grouping & RH Typing - X-Ray Chest (PA view) - PEFR - Gynecologist consultation - Final Assessment & report by Sr. Consultant, Internal Medicine Haemogram - Haemoglobin - Different Count - Platelet Count - PCV - Total WBC - Peripheral Smear - History & full General Examination Gynae check-up by Gynecologist (Women) Sr. Surgeon (Men) - MCHC - MCV - MCH Diabetic & Renal Parameters - Blood Sugar (F&PP) - Uric Acid - Urea - Micro Albuminuia - Creatinine Lipid Prifile (Including SERUM Cholesterol, HDL, LDL, Cholesterol, Triglycerides) Liver Function Tests - Total Proteins - Albmin - Globulin - A/G Ratio - SGOT, SGPT, SGGT - Alkaline Phosphatase General Tests - Complete Urine & Stool routine analysis - ECG (Resting ) - Ultrasound of whole abdomen - Blood Grouping & RH Typing - X-Ray Chest (PA view) Executive Health Check (General Health check) plus - HBSAG - TMT (Treadmill exercise Test) Complete Haemogram, ESR, Haematocrit, Blood Group (ABO, RH) Blood Group (F & PP), Blood Urea, Serum Uric Acid, Serum Creatinine, Serum Cholestrol, Lipid Profile, Stool routine examination, Urine examination, X-Ray Chest, ECG, Ultra Sound (whole abdomen), Stress screening by psychologist, Eye examination, Post examination consultation, Gynecologist conbsultation & Pap smear test, (Comprehensive Checkup) plus PFT (Routine), LFT (includes SGOT), Exercise Stress Test (TMT) Columbia Asia Block-F, Palam Vihar, Gurgaon Comprehensive Checkup Haemogram Haemoglobin, MCHC, MCV, MCH, Different Count, Platelet Count, PCV, Total WBC, Peripheral Smear Biological Parameters Blood Sugar (F & PP), Uric Acid, Uric Creatinime Lipid Profile Total Cholesterol, HDL Cholesterol, Triglycerides Screening, HDL Ratio Liver Function Test Total Protein, Globulin, SGPT, GGTP, Albumin, A/G Ratio, Alkaline Phosphates General Tests VDRL, Complete Urine analysis, ECG (Rating), Ultra Sound abdomen screening, Blood Grouping & RH typing, Faeces examination, X-Ray Chest, Consult with internal medicine, Consult with Gynecologist for female, Consult with Surgeon. Executive Health Check All tests of Batra General Health Check PLUS Ultra Sound L&U abdomen, Cardiac Function Test TMT & ECG Heart Check All tests of Executive Health Check PLUS Echocardiography & Cardiac Check up by Cardiologist Tests in Comprehensive checkup Plus TMT PFT

14 RITES LIMITED Welfare Section PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT Case No... Date:... NAME: Design. /Division. Emp. No: Place of Posting. Patient Name...Relationship Illness..... Name & location of Hospital Estimate with Breakup given by hospital... Payment of Advance 80% of Rs. Sanction may kindly be accorded for medical advance of Rs... Payment may be released in favour of by a crossed cheque. Excess amount if any paid beyond the admissibility would be adjusted as per existing rules. Dependency checked from official records SO (Welfare) JGM (Welfare & Protocol) GGM (Admn) GM (FE)

15 RITES LIMITED Welfare Section PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT Case No... Date:... NAME: Design. /Division. Emp. No: Place of Posting. Patient Name...Relationship Illness..... Name & location of Hospital Estimate with Breakup given by hospital... Payment of Advance 80% of Rs. Sanction may kindly be accorded for medical advance of Rs... Payment may be released in favour of by a crossed cheque. Excess amount if any paid beyond the admissibility would be adjusted as per existing rules. Dependency checked from official records AM(P)/ (Welfare) JGM (Welfare & Protocol) GGM (Admn) GM (FE)

16 RITES LIMITED Welfare Section PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT Case No... Date:... NAME: Design. /Division. Emp. No: Place of Posting. Patient Name...Relationship Illness..... Name & location of Hospital Estimate with Breakup given by hospital... Payment of Advance 80% of Rs. Sanction may kindly be accorded for medical advance of Rs... Payment may be released in favour of by a crossed cheque. Excess amount if any paid beyond the admissibility would be adjusted as per existing rules. Dependency checked from official records AM/P (Welfare) JGM (Welfare & Protocol) GGM (Admn) GM (FE)