FREQUENTLY ASKED QUESTIONS WITH ANSWERS ABOUT CGHS
(FAQs on CGHS are intended to provide general information and guidance needed for the CGHS beneficiaries to avail of CGHS facilities The contents must be read in conjunction with OMs/Office orders as issued from time to time. The contents are not intended to be applicable to specific /exceptional cases and no such claims may be made under it. Whenever any difference in interpretation of meaning and/or content of the facts stated here vis-a-vis the original OM/office order arises, the latter will be treated as final and binding).
1. Who are entitled for CGHS facilities?
1. All Central Govt. employees and their dependant family members residing in CGHS covered areas.
2. Central Govt Pensioners and their eligible family members getting pensions from Central Civil Estimates
3. Sitting and Ex-Members of Parliament Ex-Governors & Lieutenant Governors, Freedom Fighters
4. Ex-Vice Presidents
5. Sitting and Ex-Judges of Supreme Court & High Courts
6. Employees and pensioners of certain autonomous organizations in Delhi
7. Journalists (in Delhi) accredited with PIB (for OPD & at RML Hospital)
8. Delhi Police Personnel in Delhi only
9. Railway Board employees
2. In how many cities CGHS is presently operational?
CGHS facilities are available in 27 cities in India
- Ahmedabad
- Allahabad
- Bengaluru
- Bhopal
- Bhubaneshwar
- Kolkata
- Chandigarh
- Chennai
- Dehradun
- Delhi & NCR
- Gandhinagar
- Guwahati
- Hyderabad
- Jabalpur,
- Jaipur
- Jammu
- Kanpur
- Lucknow
- Meerut
- Mumbai
- Nagpur
- Patna
- Pune
- Ranchi
- Shillong
- Shimla
- Thiruvananthapuram
The term 'family' means and includes:-
"Husband or wife as the case may be and other dependant family members. 'Dependant' Family Members include: parents (female employee can have either her parents or her parents-in-law as dependents), sisters, widowed sisters, widowed daughters, minor brothers and minor sisters, children and step-children wholly dependent upon the Government Servant and are normally residing with the Government Servant (son upto the age of 25 or till his marriage whichever is earlier and daughter till she gets married).
Also now 'dependent' includes, dependent divorced/separated daughters ( including their dependant minor children) and stepmother.
The term 'dependent' means that income from all sources including pensions and pension equivalent of DCRG benefit is less than Rs.3500/-plus amount of DA on the Basic pension of Rs3500/- per month. This clause is to be fulfilled for all 'dependent' family members. However, there is no such clause as a dependency in respect of a spouse.
4. Is there any age limit for sons/daughters as dependent on CGHS Card?
Son is eligible till he starts earning or attains the age of 25 years or gets married whichever is earlier.
However, in case the son is suffering from any permanent disability of any kind (physical or mental) he is eligible for CGHS benefits even after 25yrs. The daughter is eligible till she starts earning, or gets married, whichever is earlier (irrespective of age)
5. Who is competent to delete the names of sons who have crossed the age of 25 years?
CMO i/c of Wellness Centre is competent to delete the name of the son aged 25
yrs and above. The computer system does not allow sons aged 25 and above to avail of medical facilities.
It is the responsibility of the beneficiary to provide information to CGHS authorities regarding any changes required in the beneficiary database especially related to death, marriage, earning status (see dependency criteria) of any card holder in the family.
7. Who is defined as a 'Person with a disability'?
A 'person with disability' as defined in 'The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995' as, a person suffering from not less than forty per cent (40%) of any disability (as given below), certified by a medical authority. "Medical authority" means any hospital or institution specified for the purposes of this Act by notification by the appropriate Government. A disability certificate from the Medical Board of a Government Hospital is required in CGHS.
Disability means blindness, low vision, leprosy-cured, hearing impairment, locomotor disability, mental retardation, or mental illness. For the exact definition of each disability please refer to 'The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995' chapter 1, section 2a. to 2z.
8. Are step-children allowed CGHS facilities?
Yes. if they are dependent on card holder and other conditions being fulfilled as in case of dependant sons and daughters.
9. Can dependent in-laws be included under family members for CGHS facilities?
A lady Government servant will be given a choice to include either her parents or parents-in-law for the purpose of availing the benefits under CGHS subject to the condition of dependence and residence, etc., being satisfied.
Yes. Your wife has the choice to make either her parents or her parents-in-law as dependants in her card.
11. What is the procedure to register with the CGHS?
Pensioners:
One can get a CGHS card made from the office of the Additional Director of the City.
Forms can be downloaded from CGHS Website. They are also available in the office of the Additional Director of the city (Additional Director Headquarters in the case of Delhi).
Documents required:
1. Application in the prescribed format
2. Proof of residence
3. Proof of stay of dependents
4. Proof of age of son
5. Disability certificate, if any in case of sons aged 25 & above, who would otherwise cease to be a beneficiary.
6. Individual passport size photos of eligible family members
7. Surrender Certificate of CGHS Card while in service ( only in those cases where CGHS Card was issued while in service)
8. Attested copies of PPO & Last Pay Certificate
9. Draft for required amount towards CGHS contribution - in the name of 'P.A.O., CGHS New Delhi' in Delhi and in the name of 'Additional Director, CGHS' of the city.
In case PPO is not ready for any reason, there is option to get a provisional card on the basis of the Last Pay Certificate. The data is uploaded in the database and a printout is issued on the same day for immediate use. Plastic cards are sent to the Wellness Centres and the beneficiaries collect the cards from there. The plastic card numbers are displayed on the notice board of the Wellness Centre for the information of the beneficiaries. SMS is sent to the mobile number of the beneficiaries reminding them to collect their plastic cards.
Serving employees:-
Serving employees submit the forms in the prescribed format enclosing photos of eligible family members and submit to the Ministry/ Department/ Office, where he/ she is employed. The application form shall be forwarded by the Ministry/ Office /Department to the office of the Additional Director CGHS of the city for preparation of the card. The plastic cards are distributed through the Wellness Centres as in the case of pensioners. SMS is sent in case of serving employees also.
12. How long does it take to get the CGHS Cards made?
Normally
computerized printout of the index card is issued on the same day. Usually, it
takes 3 to 4 weeks for the plastic card to be made after which it is delivered to the Wellness Centre, for collection by beneficiaries.
13. Whom should I approach in case the CGHS Card is not issued to me in the prescribed time?
You may contact Joint Director CGHS (HQ), in case of Delhi and Additional. Director of City in case of other cities.
14. What should I do if I lose my CGHS Card?
Application is to be submitted to the Additional Director of the city (Additional Director, CGHS Headquarters in case of Delhi) along with two photographs and an IPO for Rs. 50/- for the issue of the duplicate card. A copy of the FIR for the lost cards is also to be submitted with the application. Indian Postal Order payable to " P.A.O. CGHS Delhi" if in Delhi or "Additional Director of the CGHS City " in respect of other cities
Kindly bring the anomalies to the notice of the Joint Director, CGHS (HQ), in Delhi and to the Additional Director of concerned CGHS City in other cities, along with the necessary documents to rectify the error.
16. Is there a colour scheme for plastic cards? What are they?
Serving Government employees Pensioners, ex-MPs, Freedom Fighters, etc., Member of Parliament
Beneficiaries of Autonomous Bodies / Journalists
17. Are CGHS facilities free of cost?
No, they are not. For serving Central Government employees residing in CGHS-covered area, obtaining a CGHS card is compulsory.
The following deductions from the salary of the employees are made by the department, every month, depending upon their grade pay (wef 1/6/2009)
|
Grade Pay |
Contribution |
|
Upto Rs.1650 /- |
Rs.50/- |
|
Rs.1800/-, Rs1900/-, Rs. 2000/-, Rs. 2400/-, Rs. 2800/- |
Rs 125/- |
|
Rs.4200/- |
Rs. 225/- |
|
Rs.4600/-,Rs.4800/- Rs.5400/- Rs.6600/- |
Rs. 325/- |
|
Rs. 7600/- and above |
Rs. 500/- |
Pensioners who want to avail of CGHS facilities can make contributions either on yearly basis or one time ( ten yrs ) contribution for whole life validity.
Payment can be made by Demand Draft in favour of " P.A.O. CGHS Delhi" if in Delhi or " Additional Director of the CGHS City "
Contributions in respect of Pensioners are calculated on the basis of grade pay they are entitled to, had they been in service, but for superannuation. The details of the current grade pay can be provided to the pensioner beneficiary by the bank where his/her pension account is present.
18. What are the criteria for Entitlement of ward endorsed on CGHS
Cards like General ward / Semi-Private ward or Private Ward in CGHS Empanelled Hospitals?
Endorsement of entitlement for general/semi-private/private ward facility is done according to their basic pay / basic pension as under :
O Upto Rs. 13,950/- per month - Entitlement: General Ward O Rs. 13,960/- to 19,530/- per month -Entitlement: Semi-private Ward O Rs. 19,540/- and above - per month- Entitlement: Private Ward
There is no provision to avail CGHS facilities in respect of serving government employees residing in non-CGHS-covered areas. They are covered under CS(MA) Rules 1944.
Pensioners are eligible for CGHS facilities and can obtain CGHS cards from the nearest CGHS-covered city.
Pensioners can apply for a CGHS card with relevant documents. However, the subscriptions as applicable at current rates shall have to be paid.
No. Spouse drawing higher pay shall make the card and another spouse is eligible to avail CGHS benefits as member.
Yes, the ownership of card can be transferred in the name of the spouse on submission of required documents. The additional Director of the concerned city shall transfer the ownership of Card in the computer database and the same CGHS plastic cards with the same Beneficiary ID can be used.
No extra payment is to be made, in the case of lifetime cards. However in other cases, one has to pay 10 years subscription for life time card For example, if the spouse had contributed for seven years before he expired, the balance payment for the remaining three years is to be paid for a life time card.
Documents required :
i) Application in prescribed format
ii) Proof of Family Pension with its break up from the bank having his/her pension account.
24. How to transfer CGHS card from one Wellness Centre to other in the same city?
If there is any change in residential address, CMO I/c may be approached with proof of residence for transferring the data online from one Wellness Centre to another in the same city. CMO I/c of the new Wellness Centre will accept online, the data of the transferred card.
In respect of serving employees, the request is to be forwarded by his/her office/department.
25. I am a CGHS beneficiary at Kanpur and I am visiting Mumbai for 6 months. Can I get CGHS facilities at Mumbai? Can the same card of Kanpur continue or is a separate card to be made? From where do I get permission for the same?
Subsequent to computerization no separate permission is required and CGHS card is valid for availing facilities from any CGHS Wellness Centre in India. For any assistance, Additional Director of the city (Additional Director CGHS HQ in case of Delhi) may be contacted.
26. After retirement in 2007 I got a Lifetime Pensioner CGHS card made in Delhi. Now I am shifting to Dehradun. Can I use the same card? Do I pay again?
Pensioners shifting from one CGHS covered city to another, will have to apply to the Additional Director of concerned city for transfer of card. The card shall be transferred online and a receipt will be issued to the beneficiary, on the basis of which, the Additional Director of new city ( say Dehradun) shall receive the data. The same Plastic cards and same Ben ID will be valid in the new city. No contribution is required to be paid in respect of pensioner beneficiaries holding life time cards.
27. I live in Gurgaon but my office is in Saket. Can I avail of facilities from both the places because it is convenient for me?
Yes. Subsequent to computerization CGHS facilities can be availed from any Wellness Centre in India.
28. Whom should I contact if the doctors are not present in the Wellness Centre?
Contact CMO In Charge of the concerned Wellness Centre in the first instance. If you are unable to contact him, then contact the Additional. Director, CGHS of concerned city/ zone or Director, CGHS, if the Additional Director cannot be contacted.
29. Can the CMO or the pharmacist give a different brand than the one prescribed by the specialist?Ans:-Medicines are issued at CGHS Wellness Centres by the same brand, if available or by generic name or by any available brand name of equal therapeutic value.
30. What is the procedure for getting life-saving drugs?
Ans:-In Delhi, they can be got through CGHS Medical Store Depot, Gole Market. In Wellness Centres of satellite towns of Delhi, NCR these medicines are supplied in the Wellness Centre itself. The authority for these drugs is issued online by the CMO I/C of the parent Wellness centre where the patient is registered. A printout of the authority along with the following documents are to be submitted to the CMO I/C (for beneficiaries registered with Delhi, NCR Wellness Centres), to the Additional Director of MSD in case of beneficiaries registered with other Wellness Centres of Delhi and to Additional Director of the city in case of beneficiaries of other cities.
The documents required are:
- Prescription of specialist. of Govt.Hospital or CGHS approved private Hospita.
- Photocopy of his/ her plastic card (in case of beneficiaries from outside the city, a copy of a temporary attachment letter from Additional Director of the city (Additional Director, CGHS HQ in case of Delhi) is required to be furnished).
- Copy of permission letter, if his prescription is from CGHS approved private Hospital.
- Utilization certificate in original during subsequent visit.
31. What should I do if the Wellness Centre does not give all the medicines?
Contact CMO i/c of the concerned Wellness Centre or Addl. Director, CGHS of concerned city or Director, CGHS.
32. How long does it take to get the medicines ?
Medicines available in the Wellness Centres are issued immediately. If any medicine is not available and is to be indented through Authorized Local Chemist the same are issued on the next day.
Yes, beneficiary can collect such urgently needed drugs from the Authorized Local Chemist (ALC) on the same day, on the basis of authority form issued by Wellness Centre.
The beneficiary, after authorization by CMO I/c can purchase such drugs from open market & claim reimbursement from the ALC.
35. What should a beneficiary do, if he/ she notices some deterioration in the quality of drugs?
He /she should return the medicine to Wellness Centre & get replacement. Samples can be sent for testing through CMOI/C.
Dietary supplements are not permissible under CGHS.
37. Is the prescription of specialists of empanelled hospitals binding on the Wellness Centre?
Medicines are issued on the basis of prescriptions of government doctors. OPD treatment and issue of medicines against prescriptions of specialists in CGHS-empanelled hospitals are permitted in specified satellite cities of the Delhi NCR region (Gurgaon, Faridabad, Noida Sector 11, Noida Sector 82, Greater Noida, Ghaziabad, Sahibabad, Indirapuram). Permission can also be given( by the department for serving employees/by CMO I/C for pensioners) for follow-up treatment in empanelled hospitals for conditions relating to Cardiac surgery, Kidney transplant, Hip/Knee joint replacement, Cancer, Neurosurgery and accident cases provided the earlier treatment was carried out in the same institution with prior permission. In these cases, medicines are issued on the basis of prescriptions of empanelled hospitals as per the available brand / generic names.
38. What is the maximum period for which medicines can be given in one go?
For treatment of Chronic illnesses medicines up to '3' months are issued in one go, provided there is a valid prescription.
In case of a beneficiary visiting a foreign country, medicines up to 6' months are issued in respect of chronic illnesses, based on valid prescription and documentary support of visit to a foreign country.
The beneficiary is required to submit an application for obtaining permission from Additional Director of city/zone along with the following documents:-
1. Copy of valid CGHS card/ token card.
2. Valid prescription for six months counter signed by Specialist of Govt. Hospital.
3. Proof of going abroad leaving like the ticket, Visa etc.
39. What should I do in case of emergency or if I am unwell, say late at night?
CGHS beneficiaries have the option to go to any of the six 24 hr functional Wellness Centres in Delhi, a nearby government. hospital, empanelled private hospital or even any private hospital. In case the beneficiary chooses to go to a private empanelled hospital, pensioner beneficiaries and such other identified beneficiaries will not be asked to make a deposit for treatment in empanelled hospitals at the time of emergency. The six Wellness Centres which are functional 24*7 are located in Dr Zakir Hussain Road, Pandara Road, North Avenue, South Avenue, Timarpur and Kingsway Camp. Their contact details are given under the 'contact us' list on the CGHS website.
40. Which are the categories of CGHS beneficiaries, eligible for the cashless treatment?
- Pensioners of the Central Government drawing pension from central estimates;
- Former Vice-presidents, Former Governors and former Prime Ministers; Ex-Members of Parliament;
- Freedom Fighters;
- Serving CGHS employees;
41. What is the time within which my medical claim is to be reimbursed?
Ans:-If all documentation is complete medical claims of pensioners are cleared in 45 days.
42. What can I do if my claim is unnecessarily delayed?
A Claims Day is held in the O/O the Additional Director of city (and in the 4 zones in Delhi) on the third Thursday of every month, to discuss grievances related to medical claims. One can register one's name for the Claims' Day through CMO I/C of the Wellness Centre.
Ans:-Each empanelled hospital is expected to have a Nodal Officer at the reception counter to address issues related to CGHS beneficiaries. If they are incapable of resolving the problems, then contact CMO I/C of the Wellness Centre where you are registered or Additional. Director, CGHS of concerned city/zone or the nodal officer for grievance redressal.
44. What are the facilities available to me if I am a pensioner in a non-CGHS area ?
Pensioners residing in non-CGHS covered areas have the option to become CGHS beneficiaries and avail of CGHS facilities from the nearest CGHS-covered city.
Pensioners residing in non-CGHS areas have also the option to avail Fixed Medical Allowance of Rs300/- per month and opt not to avail CGHS facility.
Pensioners residing in non-CGHS areas have also the option to avail Fixed Medical Allowance of Rs300/- per month for OPD treatment and obtain a CGHS card from the nearest CGHS-covered city for inpatient facilities under CGHS. No OPD medicines shall be issued from Wellness Centres in such cases.
CGHS pensioner beneficiaries( and their dependant and eligible family members) who are holding a valid CGHS Card and residing in a non-CGHS area shall be eligible to obtain inpatient medical treatment and also follow-up treatment from Govt. Hospitals / CS(MA) /ECHS approved hospitals on proper referral from CGHS Wellness Centre and submit the medical reimbursement claim to the Additional. Director/ Joint Director of CGHS of city where the CGHS card is registered.
In case of medical emergency , treatment may be obtained from any hospital and a medical claim shall be submitted to Additional Director, CGHS of the concerned city.
Reimbursement shall be limited to the CGHS rates of the city where the card is registered and as per the ceiling rates and ward entitlements or as per actual, whichever may be less.
45. What is the system for availing the services of specialists in Wellness Centres ?
Prior registration is required for appointment with specialists in CGHS Wellness Centre, where specialist services are available.
However, in case of emergency contact CMO I/C of the Wellness Centre for consulting specialist without a prior appointment.
46. What are the documents to be submitted for any investigation by an empanelled diagnostic centre?
The following documents are required:
a. Original or self-attested copy of prescription of CGHS Doctor / Government specialist
b. Copy of CGHS Card of the patient and main card holder.
At the Wellness Centre 'Local Advisory Committees' are formed. CMO i/c holds a meeting with Local Advisory committee members once a month on the second Saturday to discuss local Wellness Centre-related issues..
Apply to CMO I/c of the Wellness Centre where your CGHS card is registered, within 90 days of discharge/completion of treatment procedure along with the following documents :
1) Medical Reimbursement Claim (MRC) forms duly filled in
2) Check list
3) Copy of Discharge summary
4) Original Hospital bills with break-up
5) Receipts in original
6) Copy of the valid CGHS Card
7) Copy of cancelled cheque showing bank details for ECS payment along with the mandate form.
8) Copies of other documents issued by the hospital.
The whole set of MRC is to be submitted in duplicate
MRC forms are available with CMO I/c and can also be downloaded from CGHS Website.
The MRC after being scrutinized in the Wellness Centre will be submitted online to the Additional Director. An acknowledgement printout with the computer-generated MRC number will be given. This MRC number is to be quoted for any further correspondence related to the claim.
Serving employees in similar cases shall submit the medical claim to his department.
49. My husband/wife was a CGHS main card holder. He/she was sick and died while in hospital. How do I get the medical claim reimbursed?
Apply to CMO I/c of Wellness Centre with the same documents as above. In addition, the following need to be enclosed:
1. Copy of Death summary
2. Death Certificate
3. Affidavit on non-judicial Stamp paper of yourself being Legal Heir and
NOC from other legal heirs in favour of the claimant. It is also to be noted that the CMO I/C is to be informed regarding the death of the cardholder but till such time that the claim is settled, the main cardholder's name is not to be deleted from the database as it would then not be possible to submit the MRC on-line.
50. My original claim papers having bills, receipts of hospital treatment are lost. Can I claim on duplicate papers?
Yes, it can be claimed with an affidavit on non-judicial stamp paper. The duplicate bills need to be verified by the treating doctor. Details of the Draft for Affidavit may be seen in the instructions sheet appended to Medical Reimbursement Claim (MRC) Form available on the CGHS website and with CMO I/c.
51. I retired in Dec 2011. Due to certain reasons I had to go to my native place in Uttaranchal and could not make a pensioner's CGHS card. In May 2012 I came to Delhi and had heart attack. In emergency, I was treated in a private hospital. I got CGHS Card made after discharge but I have been refused reimbursement of the expenditure incurred.
After retirement, three months grace period is given to get the CGHS card made. There are two conditions which may arise:
(a) Pensioner beneficiary does not have a CGHS card and the treatment is taken within the grace period of three months from the date of retirement-
This will be allowed and expenditure reimbursable subject to the condition that the beneficiary has either obtained or applied for a CGHS pensioner card with all documents and requisite CGHS subscription within one month of the expiry of the grace period of three months.
(b) Pensioner beneficiary does not have a CGHS card and the treatment is taken after the grace period of three months from date of retirement- This will not be reimbursable unless the beneficiary has obtained a valid CGHS card or has applied for CGHS pensioner card with all documents and requisite CGHS subscription prior to taking such treatment.
Reimbursement for treatment taken in a private hospital under medical emergency shall be considered as per CGHS rates only.
53. Is treatment for IVF reimbursable?
IVF treatment is approved under CGHS. The details may be seen as per Office Memorandum Z.15025/5/2011/CGHS III/CGHS(P) dated 22.11.2011 , which can be downloaded from CGHS Website.
54. Are ambulance charges reimbursable?
Yes. Ambulance charges are reimbursable within the city , if there is a certificate from treating doctor that conveyance by any other mode would definitely endanger patient's life or would grossly aggravate his/her condition.
Yes, first the bills are to be submitted to the Insurance Company. Duplicate bills and vouchers duly verified with the stamp of the Insurance Company along with a certificate from the Insurance Company indicating the amount for which the beneficiary has received credit from them needs to be submitted along with the usual MRC forms and checklist. These may be submitted to CGHS by Pensioner CGHS beneficiaries and to the department by serving beneficiaries. Reimbursement would be done at CGHS rates or actual whichever is less. However, the total reimbursement from both sources should not exceed the actual expenditure.
Expenditure for treatment in private hospitals is considered only if the treatment was taken under emergency. Reimbursement is done at CGHS-approved rates and as per CGHS guidelines.
57. In emergency who are all entitled to get treatment at Private Empanelled Hospital?
Any beneficiary holding a Valid CGHS card.
58. I want to get my Cataract Surgery done at a Private empanelled hospital. How can I get it done?
Beneficiaries are required to obtain advice from a Government. Specialist for Cataract surgery (except beneficiaries attached to Wellness Centres in Delhi NCR who can obtain advice from a specialist of empanelled hospital after due referral by CMO I/C). Pensioners will then apply to CMO I/c of the Wellness Centre for permission to obtain treatment at the empanelled hospital of his /her choice.
Serving employees will apply for permission to his / her Department/office.
The advice of Government specialists is required only for the specific treatment procedure/investigation to be undertaken. There is no need to specifically refer to any empanelled hospital/ diagnostic lab. It is the choice of the beneficiary to be under treatment/investigation at any of the empanelled hospitals / diagnostic laboratories after obtaining permission from the competent authority.
As per CGHS guidelines, there is no provision for OPD referrals to privately empanelled hospitals except in satellite towns of NCR.
Journalists are entitled for OPD treatment from Wellness Centres and treatment from Dr.RML Hospital. Journalists are not entitled to reimbursement for treatment from empanelled hospitals. They can, however, get in-patient treatment for themselves and their dependent family members
at CGHS Semi-Private Ward rate at CGHS empanelled hospitals, on payment.
62. I am a serving employee of an autonomous body, holding a CGHS card. Who will give me permission for treatment on the recommendation of a Government specialist?
Permission for treatment at empanelled hospitals / diagnostic labs shall be granted by the office of the organization where the employee is serving.
63. I am a pensioner employee of an autonomous body, holding a CGHS card. Who will give me permission for treatment on the recommendation of a Government specialist?
Permission for treatment at empanelled hospitals / diagnostic labs shall be granted by the office of the organization from where the employee retired.
64. Is Penfill Injection provided under CGHS?
An insulin pen is not supplied under CGHS. But, Insulin Pen Cartridges are supplied under CGHS
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