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  • Form For Medical Rembursement

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    Midun Mohan
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    Medical reimbursement

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    Form for Medical Rembursement

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    Medical reimbursement

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    Download as pdf
    8 views4 pages

    Form For Medical Rembursement

    Uploaded by

    Midun Mohan
    Medical reimbursement

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    Download as pdf
    of 4
    Act FORM-1 FORM OF APPLICATION FOR MEDICAL REIMBURSEMENT (See Rute [8] 1) OULD BE: USED FoR EACH ETIENT) "Name and designation of government as ‘Servant in block letters (Office inwhich employed eee Pay of the Government servant as defined in the fundamental Rules and any other empioy- ‘ment wich shoula be snown Separately 7 Plate of duty. — eee ‘Actual resisential Adaross [Name of the patient and his ther relation ‘Government Servant (SB. in the case of children, stage '5No.of Child (Date tothe (i) Numberin oxder of bith (0) + Total number of children Piace at which patient flit Detais of the amount claimed. 1. Medical attendence := (Fees of consulstion indicating - (@) The name and designation of the ‘Medical Officer consulted and hospital or dispensary to which attached (©) The number and dates and consulting andthe fees paid for consultation (e) Whether consultation werehad at gg te nosprat at tne consuting room fof the officer or at the residence of the patient. (i) Charges for pathological, bacterio Iogical. radiological or other similar tests undertaken during dignosis ‘ncbeating {(@) The Name of the hospital or laboratory where the test ‘undertaken and, (b) Where the tests were undertaken fon the advice ofthe authorised medical attendant and ifs, Ceniicate to mat errect snow be attached (i) Cost of medicines purchased {rom the market (List of medicines, Cash memo and the essentiality certificate should be attached) Hospital treatment Charges for hospital treatment including separately the charges for- (Accomodation state whether it was according __ to the status or pay of the Government Servant & in cases where the accomodation in the higher than the status of the Government servant a cerlficate should be attached to the ‘effect that accomodation to which he was ‘entitled was not available. (i) Dist (ii) Surgical operation or Medical reat (v) Pathological bacteriological or other simitar tests indicating (@) The name of the hospital or laboratory at which undertaken and, (®)_ Whether undertaken on the advice of the medical officer Incharge of the case at the hospital if so a certificates fo thal effect should be attached, (Medicines. (vi) Special Medicines. (ist of medicines case memos & the essentiaity cortilicate should be attached) (vi) Special nursing ic.nurses specially engaged {or the Patient-State whether they were employed fon the advice of the medical officer in-charge of the case at the hospital or at the request of the Government servant or patient in the former case a cerificate from the M.O. |. C of the case and undersigned by the medical superintendent of the hospital should be attached (i) Any othet*charges @. 9. charges for electric _ light fan, neater, air- conditioning, ete. State ‘alco what her the faciities referred to are a part of facilties normally provided to all Patients and no cholce wa lefl to Patient Note -If treatment was received by the Government ‘servant at his residence: give particulars of ‘such treatment and altached contiticate trom authorised Medical attendant. 10) Total amount claimed. 11) Ust of enclosures. DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT I HEREBY DECLARE THAT the statements in application are true to the best of my knowledge 4nd belief & that the person for whom medical expenses were incurred is wholly dependent upon me. : ‘Signature of the Government Servant "Date: =m ‘and Officer {o which attached a FORM-1 FORM OF ESSENTIALITY CERTIFICATE See Rule 8 (2) ‘A In case of medicines not included in the pricod vocabulary ofthe Medical Store Depot. CERTIFICATED that Shri/Smt Kumari_ Sonnwife/Daughter of Shri ‘employed in the has been under my wentment from, 6. fer (ame of the disease) at the hospital as ‘n-doorfout door Patient and thatthe under mentioned medicines has been prescribed by me inthis, connection. These medicines are not included on the priced vocabulary of Medical Stores not or they Preparation which are primarily food, toilets or dsinfatants, These medicines were absolutely essential {or the treatment of the aforesaid patient NAME OF MEDICINES 10 1" 12 14 CERTIFICATE ‘This is certify that the Medicines presented out of PV.MS, list were essenties to the patient ‘Signature and designation ofthe authorised ‘medical attendantSignature ofthe Medical Officer ic of case at the hospit ni =35 B-IN CASH OF MEDICINES INCLUDED IN THE PRICED VOCABULARY OF THE MEDICAL STORES DEPOT. | CERTIFY THAT She/Shrimatikiumart, ‘Son!Wite/Daughter of Shri ‘employed in the as been under ny for (Name of the disease) at the hospital as in

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