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    Exp Estimate

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    nelsng
    This document is an estimate of expenditure form for the Karunya Benevolent Fund, which provides financial assistance for medical treatment. It requests information such as the patient's name, address, diagnosis, proposed treatment details including costs, and whether other financial assistance is being received. The form must be completed by the treating doctor, authorized hospital representative, and submitted with applications for assistance from the fund.

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    Exp Estimate

    Uploaded by

    nelsng
    21 views1 page
    This document is an estimate of expenditure form for the Karunya Benevolent Fund, which provides financial assistance for medical treatment. It requests information such as the patient's name, address, diagnosis, proposed treatment details including costs, and whether other financial assistance is being received. The form must be completed by the treating doctor, authorized hospital representative, and submitted with applications for assistance from the fund.

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    This document is an estimate of expenditure form for the Karunya Benevolent Fund, which provides financial assistance for medical treatment. It requests information such as the patient's name, address, diagnosis, proposed treatment details including costs, and whether other financial assistance is being received. The form must be completed by the treating doctor, authorized hospital representative, and submitted with applications for assistance from the fund.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    21 views1 page

    Exp Estimate

    Uploaded by

    nelsng
    This document is an estimate of expenditure form for the Karunya Benevolent Fund, which provides financial assistance for medical treatment. It requests information such as the patient's name, address, diagnosis, proposed treatment details including costs, and whether other financial assistance is being received. The form must be completed by the treating doctor, authorized hospital representative, and submitted with applications for assistance from the fund.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    KARUNYA BENEVOLENT FUND

    (Directorate of State Lotteries)


    ESTIMATE OF EXPENDITURE
    (To be obtained from the consulting Doctor & countersigned by the authorized person of the Hospital concerned and submitted along with the application for financial assistance under Karunya Benevolent Fund)

    1. Name & Address of the Hospital:

    2. Name of Patient : 3. Address : (as per hospital records) i. House Name/No. : ii. Place/Village:

    iii. Grama Panchayat/Municipality/Corporation: iv. Post Office: v. Taluk: 4. Age: 6. Registration No. / I P No. : 7. Diagnosis: PIN: vi. District: 5. Name of Father/Mother/Husband: Date :

    8. Proposed date for Operation: 9. Priority of treatment/Operation: Emergency / within 3 months/within 3 to 6 months 10. Approximate period of treatment required: 11. Approximate expenditure for a. Investigations c. Surgery e. Radiotherapy Rs. Rs. Rs. b. Drugs Rs.

    d. Chemotherapy Rs. f. Hospital stay Rs. Rs.

    g. Supportive care Rs. Total Estimated expenditure

    h. Other items : Rs.

    12. Whether the patient has availed / proposed to avail any financial assistance from State /Central Govt. If so please give details:

    13. Remarks:

    Signature Name & Designation of the Consulting Doctor

    Signature Name & Designation Head of the Hospital/Authorized signatory

    Date

    (Office seal)

    Details of Hospitals Bank A/c to which the Amount is to be transfer credited A/c No. Name of Bank IFSC Code

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