g{rGT d'qR Frrfr frfrtg / BHARAT sANCHAR NIGAM LIMITED

(8{fGT {l{fiR EF'[ SWF-JT) / (Govt.oflndiaundertaking)

fr(r{Kl-d(ril 3Tffi gRI 3t+qirrfr fr {orora inl IIiIITUIIFI

Certificate of visit of BSNL officer in hospital
fr(r{T(rf,(rfr fi fitqfi g€-gK fii Z AspertheinstructionofBsNLlvisitedthe
3,l-€qiilFT d Z in hospital at .-q$ Z
--L
am.pm. cf,l / on artlq / dt. 3i1-{ tn{TI lfi' / andfound that
(ltrfr qiT Ffliq./name of patient) titr6-{uf fr. / regd.no.
Erg d/ wardno. df z in s.irct / Dr.
* 3iildlrT sqrlR d G tt z itundergoingtreatment'

tdff h ffifud Fff{ur rITq arql / Following particular of the patient observed.
(1) rfi fi drfiq
Date of admission

(?') rtar ot ara

Name of disease

(3) q'ffi iF'r;nifr

Name of employee

(4) qfr;nff
Designation

(s) o,ffir *'snr ftqdr

Relationship with the employee

(6) 6qgqr;nr6 (rf;3IK(r{T 61f ;t.

BSNL MRS Card No.

rlzfi z o.ffiI Fdp qr G sr{R t sqrerff tl

The patient / employee is satisfied with the fteatment being given.

sf,h qrr ruTrdq 6{friH fi rrgsrt t frttgrratta (rf;3rr(':{t fi 3itrrtd sTltIR tA fi

fr(r 3{fu{ia Rmffi qnr rKr tl
As per the documents available with him/her, he/she is found to be the authorised beneficiary to
take ffeatment under the BSNL MRS.

fcaio / Date;-

FFilqfi / Sign' :-
3{fufr.ftT 6'r ;IrfrlName of officer :-

{qr {fl ft' grq / withrubber stamp :