ESSENTIALITY CERTIFICATES

CERTIFICATE A
(To be completed in the case of patients who are admitted to hospital for treatment)

Certificate granted to Mrs/Mr. ______________________-_ Wife/Son/Mother/Daughter

of Mr. _______________________ employed in 1650 PNR COY(GREF).
I Dr. ______________________here by certify.

a) That I charged and received Rs. for consultations on (date

to be given) at my consulting room /at the residence of the patient.

b) That charged and received Rs. ____________ for administering

_______________ intra-venous/intramuscularly/subcutaneous injections on
_____________(date to be given) at _____________ my consulting room /the residence
of the patient.
c) That the injections administered were not/were for immunizing or prophylactic
prose.

d) That the patient has been under treatment at

________________________hospital /my consulting room and that under mentioned
medicines prescribed by me in this connection were essential for the recovery/prevention
of serious deterioration in the condition of the patient. The medicine are not stocked in
the _________________-_(Name of hospital) for supply to private patients and do not
include proprietary preparations for which cheaper substance of equal therapeutic value
are available not preparations which are primarily food, toilets or disinfectants.

DETAILS OF MEDICINE

S/NO BILL No DATE PARTICULARS A/U QTY PRICE

01

02

03

e) That the patient is/was suffering from ________________________ and is /was

under my treatment from ______________________ to
____________________________

f) That the patient is/was not given prenatal or postnatal treatment.

g) That the X-ray, laboratory test, etc. for which an expenditure of Rs.
__________________ was incurred was necessary and were undertaken on my advice
at ______________________________ (Name of the hospital or laboratory).

h) That I referred the patient to Dr ___________________________ for specialist

consultation and that the necessary approval of the _____________________________
(name of the chief Administrative Officer of the State) as required under the rules was
obtained.

i) That the patient did not require /required hospitalisation.

Dated: (Sig. of Med Offr with seal)

 Total No of cases Total No of case Total No of case out
requiring revision Total No of case revised revised out of (2) standing Reason for outstanding

1 2 3 4
Pre Post Post Post
2016 2016 Pre 2016 Post 2016 Pre 2016 2016 Pre 2016 2016
Pension cases 569 459 79 19 25 - 381 - 459 Nos cases already fwd to pensioners for want oft
Family
pension cases requisite details but 51 nos details received from
Total pensioners. 44 cases reviewed. ( 19 cases has already
been fwd to AO HRK. Now 25 cases ready for signatures of HOO
21 Cases return back recd by this office due to death/change o