IN SERVICE PENSIONER UNIVERSITY OF HYDERABAD MEDICAL REIMBURSEMENT CLAIM FOR INPATIENT TREATMENT WITH OUT ADVANCE : NIL Pension |.D. No. S.B.1/ AB. Bank Alc No. Note : Separate application form should be submitted for each patient Name & Designation of the employee (IN BLOCK LETTERS 2. Department / Branch 3. Pay/ Basic Pension Rs. 4. Dependent Telephone No. Cell 5. Actual residential Address 6. 1) Name of the patient and his / her relationship to the employee (age may please be indicated in case of children) ii) if married, whether Wife / Husband is employed 7. Address / place at which the patient fel il * 8. Details of charges paid for Specialist service indicating : 1) Consult Ii) Injections on. = 9. Charges for hospital treatment ‘and Amount paid RS... _and Amount paid R: ion on... a) For accommodation - whether it was Rs. according to the status or pay of the university ‘employee. If higher accommodation than the entitled one is provided a certificate from the Medical Officer in-charge to that effect that the ‘accommodation to which the University employee was entitled was not available is to be attached. b) Operation Theatre Charges Rs, c) Surgical operation / Medical treatment’ confinement. d) Pathological, bacteriological, radiological or other similar lab tests. i) Amount paid Rs. ii) The name of the hospital or lab /at where undertaken A certificate of the medical officer in-charge of the case, at the hospital who advised the tests. e) Medi 1e8 including special medicines Rs. f) Nursing charges - duly supported by a certificate of the medical officer advising such services.9) Ambulance Charges - receipts indicating the amount, the journey to and fra undertaken. (along with essentiality certificate issued by a Govt. Doctor ( applicable if use of Govt. Vehicle) h) any other charges eg. electric lighting, fans, heater air conditioning etc., indicating whether the facilities normally provided to all Patients and no choice was left to patient 10. Total amount claimed 11. List of enclosures |) Essentiality Certificate ‘B’ dated. li) (2) Doctor's prescription dated... (b) Certificate dated, iit) Cash memo Name & Address of Name of the medicine No. & Date the medical shop and quality. (¥)_(@)__ Receipt for room rent paid No. (©) Receipt for diet charges No.... (c) (d) fe) 12, Declaration ; Thereby declare that the statement made in he application are true to the best of my knowledge and beliof and that the patient for whom medical expenses were incurred is wholly dependent upon me. NA The, application MUST be filled in all respects and Submitted to the office failing with the same will not Station : Date Signature of the University employee FOR USE IN MEDICAL REIMBURSEMENT SECTION |. Fee paid for accommodation Rs Ill, Medical Advance Re. Consultation charges Rs less refund of Advance Rs. Laboratory Test Rs Outside Medicines Rs. eo oreee Go Medicines provided in Hospital Rs. Bi Pass for Re. Hl. Surgical Procedure Recovery / Payment — Re. Operation Theatre Re. . ‘Surgeon Charges Rs. Anaesthalist Charge Re. for other services Re. (Rupees. 1) Passes for payment of R: only) i) Adjustment Rs. ( Rupees, only) iil) _ Recovery of Rs. Dealing Asst. S.0. AR. DR. Fo.This Certificate granted to Mrs. / Mr. Miss, wife/Son/Daughter of employed in the University of Hyderabad CERTIFICATE ‘B’ (To be filled in & signed by the medical Officer in - charge of the. .case at the hospital) (2) that the patient was admitted to hospital on the advice of / on my advice. (») _ that the patient has been under treatment at. and that the undermentioned medicines prescribed by me in this connection were essential for and the recovery / prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the .. for (name of the hospital) supply to private patients and do not include proprietary preparations for which cheaper sub ‘stances of equal therapeutic value are available nor preparations which are primarily foods toilets or disinfectants. : PRICE NAME OF MEDICINES Rs. ps. ° (a) e) U) That the injections administered were / were not for immunising or prophylactic purpose. that the patients / was suffering from. and /was under my treatment .. That the X-ray, Laboratory tests. etc. for which an expenditure of Rs.. incurred were necessary and were undertaken on my advice at. (name of hospital or laboratory) ‘That | Called on Dr. for specialist consultation and that the necessary approval of the .. (name of the Chief Admn. Medical Officer of the State) as required under the rules; was obtained. N.B. : All the Claims should be filled in all respect failing which, The Bill Will NOT BE entertained Signature and Designation of the Medical Officer-in-charge of the case at the hopital.PART-B | Certify that the patient has been under treatment at the (name of the Hospital was and that the service of the special nurses for which an expenditure of R: Incurred vide bills and receipts attached, were essential for the recovery / prevention of serious. deterioration in the condition of the patient. Signature of the Medical Officer -in-charge of the case at the Hospital. (Rubber Stamp of the Medical Officer /C) COUNTERSIGNED MEDICAL SUPERINTENDENT hospital * | Conlify that the patient has been under treatment at thi hospital and that the facilities provided were the minimum which were essential for the patient's treatment. ‘Signature Rubber Stamp of the Medical ‘Superintendent NB : Certificates not applicable should be struck off. Ceitificate 1. (d) is compulsory and musf be filled in by the medical Officer in all cases. “The minimum facilities certificates may be signed either by the medical Superintendent of the Hospital concerned or another Gazetted medical Officer who has been authorised in this behalf by the Medical Superintendent. (GOL, MH.0.F 2-35/52SG(H.L), dated the 19th September. 201-201 )