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A registered 80G & 12A public trust · Reg. No. F-22838 (AU) · Chhatrapati Sambhajinagar (Aurangabad)

+919767344055

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Register for Assistance

Please fill in the details below. Fields marked with * are required. It takes about three minutes.

Submitting this form does not itself guarantee scheme eligibility, treatment approval, package authorisation, admission or reimbursement.

About the patient
10-digit Indian mobile number. We will call you on this number.
Give either the date of birth or the age.
Gender *
Optional. If you give it, we will email your reference number.
What you need help with
What do you need help with? *
Do you have an Ayushman card?
Are you already registered under MJPJAY?
How urgent is this?
Medical details
A few lines is enough. Please do not paste full medical reports here — upload them instead.
Documents & consent
PDF, JPG or PNG. Up to 6 files, maximum 5 MB each.
Ayushman card, identity proof, ration card (if relevant), medical reports, prescriptions.

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