अखखिल भारतीय रु ररजारञा संस्थारञा, भर

ु ञाेशरत
All India Institit of Mtdical Scitncts, Bhtbantswar

APPLICATIONFORM FOR CLAIM FOR MEDICAL BILLS

Form of applicatoo for claimiog refuod of medical expeoses iocurred io coooectoo with medical ateodaoce aod/ or treatmeot for Ceotral
Goveromeot servaots aod their families – for medical ateodaoce/ treatmeot takeo both from the Authorized Medical Ateodaot aod a
Hospital.

1. Name aod desigoatoo of the Goveromeot Servaot (Io :

block leterss
is Whether married or uomarried :
iis If married, the place where wife/ husbaod is :
employed
2 Office io which employed :
3 Pay of the Goveromeot servaot as defoed io the :
Fuodameotal Rules, aod aoy other emolumeots
which should be showo separately
4 Place of duty
5 Actual resideotal address
6 Name of the pateot aod his/ her relatooship to the
Goveromeot Servaot. N.B. io the case of childreo
state age also
7 Place at which the pateot fell ill
8 Details of the amouot claimed :
I. Mtdical Attndanct
i) Ftts for constliaton indicatnn
as The oame aod qualifcatoo of the Medical Officer
coosulted aod the hospital or dispeosary to which
atached
bs The No. aod Dates of coosultatoo aod the fee paid
for each coosultatoo
cs The No. aod date of Iojectoo aod the fee paid for
each iojectoo
ds Whether coosultatoo aod/or iojectoos were had at
the hospital, at the Coosultog Room of the M.O. or
at the resideoce of the pateot
ii) Charnts for paiholonical, bacitriolonical,
radiolonical, or oihtr similar itsis tndtriaktn
dtrinn diannosis indicatnn
as The oame of the hospital or laboratory where
uodertakeo; aod
bs Whether the tests were uodertakeo oo the advice of
the authorized medical ateodaot. If so, a certfcate
to that efect should be atached.
iiis Cost of medicioes purchased from the market (Cash
memos aod the esseotality certfcate should be
atacheds.
II. Hospital Treatmeot
Name of the hospital

Charges for hospital treatmeot, iodicatog separately the charges for -

is Accommodatoo (State whether it was accordiogly to
the status or pay of the Goveromeot Servaot aod io
cases where the accommodatoo is higher thao the
status of the Goveromeot servaot, a certfcate
should be atached to the efect that the
accommodatoo to which he was eottled was oot
availables.
iis Diet
iiis Surgical operatoo or medical treatmeot or :

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 अखखिल भारतीय रु ररजारञा संस्थारञा, भर
ु ञाेशरत
All India Institit of Mtdical Scitncts, Bhtbantswar

coofoemeot
ivs Pathological, bacteriological radiological or other :
similar tests iodicatog :
as The oame of the hospital or laboratory at which
uodertake, aod
bs Whether uodertakeo oo the advice of the Medical
Officer io charge of the case at the hospital. If so, a
certfcate to that efect should atached.
vs Medicioes
vis Special medicioes (Cash memos aod the esseotality
certfcate should be atacheds
viis Ordioary oursiog
viiis Special oursiog i.e., ourses, specially eogaged for the
pateot. State whether they are employed oo the
advice of the medical officer io charge of the case at
the hospital or at the request of the Govt. Servaot or
pateot. Io the former case a certfcate from the
medical officer io charge of the case aod
couotersigoed by the Medical Superioteodeot of the
hospital should be atached.
ixs Ambulaoce charges (State the jouroey – to aod from
– uodertakeos
NOTE 1 : If the treatmeot was received by the Govt. servaot at his resideoce uoder Rule 7 of the C.S. (M.As Rules,
1944 give partculars of such treatmeot aod atached a certfcate from the authorised medical ateodaot as
required by these rules.
NOTE 2 : If the treatmeot was received at a hospital other thao a Govt. Hospital, oecessary details aod the
certfcate of the authorized medical ateodaot that the requisite treatmeot was oot available io the oearest Govt.
Hospital should be furoished.
III. Coosultatoo with Specialist – Fees paid to a specialist or a Medical Officer other thao the authorised
medical ateodaot, iodicatog -
as The oame aod desigoatoo of the Specialist or
Medical Officer coosulted aod the hospital to which
atached.
bs Number aod dates of coosultatoos aod the fees
charged for each coosultatoo.
cs Whether coosultatoo was had at the hospital, at the
coosultog room of the Specialist or Medical Officer,
or at the resideoce of the pateots, aod
ds Whether the Specialist or Medical Officer was
coosulted oo the advice of the authorized medical
ateodaot aod the prior approval of the Chief
Admioistratve Officer of the State was obtaioed. If
so, a certfcate to that efect should be atached.
09. Total amouot claimed :
10. Less advaoce takeo to :
11 List of eoclosures :

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statemeot io the applicatoo is true to the best of my koowledge aod belief aod that the persoo for
whom medical expeoses were iocurred is wholly depeodeot upoo me.

Dait :
Sinnaitrt of iht Govtrnmtni Strvani
and Ofct io which atachtd

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 अखखिल भारतीय रु ररजारञा संस्थारञा, भर
ु ञाेशरत
All India Institit of Mtdical Scitncts, Bhtbantswar

Chtck Lisi for Paymtni

(Payment against the bills in respect of claiming refund of medical expenses AIIMS, Bhubaneswar)

These bills are io respect of claimiog refuod of medical claims of …………………. of ………………AIIMS,
Bhubaoeswar.

From :
Dated :
Amouot :

The followiog iodicatve checks have beeo exercised before preseotog the bill for paymeot.
Sl Descriptoo Observatoo Yes/No/NA
No
1 Name & Desigoatoo of the Govt. servaot :
2 Whether married. If married, the place :
where wife/ husbaod is employed
3 Office io which employed
4 Pay of the Govt. Servaot as defoed io the :
fuodameotal rules & aoy other emolumeots
which should be showo separately
5 Place of duty
6 Name of the pateot & his/her relatooship
with the Govt. Servaot. NB: Io case of
childreo state age also place wheo pateot
fall ill.
7 Nature of illoess claimed
8 Details of the amouot claimed
9 Fee for coosultatoo iodicatog
10 The oame & desigoatoo of the medical
officer coosulted & the hospital or
dispeosary to which atached
11 The oumber of dates of iojectoo & the fee
paid for each iojectoo
12 The oumber & dates of coosultatoo & has
fee paid for each coosultatoo
13 Cost of medicioe cash memo & the
esseotality certfcate should be atached
14 Total amouot claimed Rs.
15 Net amouot claimed Rs.
16 List of eoclosures :
Dait:

Sinnaitrt of Claimani Sinnaitrt of Mtdical Stptrinitndtni

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 अखखिल भारतीय रु ररजारञा संस्थारञा, भर
ु ञाेशरत
All India Institit of Mtdical Scitncts, Bhtbantswar

APPENDIX XI

ESSENTIALITY CERTIFICATE – “Ä”

(To bt compltitd in iht cast of pattnis who art noi admittd io hospiial for irtaimtni)

Certfcate graoted to ………………………….. of……………………………….,employed io AIIMS, Bhubaoeswar.

1. Dr…………………….., AIIMS, Bhubaoeswar is hereby certfy, that I charged aod received Rs. ….for coosultatoo at my
coosultog room oo dt.………..at my coosultog room.

as That I charged aod received Rs………….. oot applicable from admioisteriog Nil iotramuscular iojectoos or
subcutaoeous oo dt.……………..AIIMS Bhubaoeswar
bs That the iojectoos admioistered were oot immuoiziog or prophylactc purposes.

That the pateot has beeo uoder treatmeot at All Iodia Iosttute of Medical Scieoces, Bhubaoeswar hospital/ my
coosultog room aod that the uoder meotooed medicioes prescribed by me io this coooectoo were esseotal for the
recovery/ preveotoo of serious deterioratoo io the cooditoo of the pateot the medicioes are oot io stock io the AIIMS,
Bhubaoeswar (oame of the hospitals for supply to private pateots aod do oot ioclude proprietary preparatoos for
which cheaper substaoces of equal therapeutc value are available oor preparatoos which are primarily food, toilets or
disiofectaots.

Sl No Name of Medicioes Amouot io Rs.

That the pateot is/was suferiog ……….is/was uoder treatmeot from…………. That the pateot is/was oot giveo pre-oatal
treatmeot.

cs That the x-ray, laboratory test etc. for which ao expeoditure of Rs. N/A was iocurred was oecessary aod were
uodertakeo oo my advice at AIIMS, Bhubaoeswar.
ds That I referred the pateot to ..N/A.. for specialist coosultatoo aod that the oecessary approval of the (Name
of the Chief Admioistratve Medical Officer of the states as required uoder the rule was obtaioed.
es That the pateot did oot require/ required hospitalizatoo.

Dated :
Sigoature aod desigoatoo of Medical Officer
aod hospital/ dispeosary to whom atached
Notes :
(1s Certfcates oot applicable should be struck of. Certfcate (cs is compulsory aod must be flled io by the
Medical Officer io all cases.
(2s Io cases where double the rates of coosultatoo fees are charged by the Authorized Medical Ateodaot for
oight visits (betweeo 10.00 PM to 6.00 AMs the Authorized Medical Ateodaot should furoish a certfcate
showiog why the oight coosultatoo was oecessary. (G.I.M.H.O.M. No.F.28-57/60-MI dated 4 th April, 1962s

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 ESSENTIALITY CERTIFICATE
CERTIFICATE –B

(To be completed io the case of pateot who are admited to hospital for treatmeots

Certfcate graoted to Mrs/Mr/Miss __________________________________

____________________, employed io the ____________________ hereby certfy:-

PART-A

(To be sigoed by the medical officer io charge of the case of the hospitals.

(as That the pateot was admited to hospital oo the advice of Dr. ____________, of
____________________ oo my advice.

(bs That the pateot has beeo uoder treatmeot at AIIMS, Bhubaoeswar aod that the uoder
meotooed medicioes prescribed by me io this coooectoo were esseotal for the recovery/preveotoo
of serious deterioratoo io the cooditoo of the pateot.

(cs The medicioes are oot stocked io the AIIMS, Bhubaoeswar for supply to private pateots aod
do oot ioclude proprietary for which cheaper substaoces of equal therapeutc value are available oor
preparatoos which are primarily foods, toilets or disiofectaots.

Sl No Name of Medicioes Qty Prices

1. Origioal Medicioe bills atached __ Nos -

(ds That the pateot is/was suferiog from _______________ aod is/was uoder my treatmeot
from ______________ to ______________.

(es That the X ray laboratory test etc. for which ao expeoditure of Rs_________/-. (Name
of Hospital or Laboratory (_______________origioal bills atacheds.

(fs That I called/referred the pateot to Dr........................ for specialist coosultatoo aod that the
oecessary approval of the........................ (Name of the Chief Admioistratve Officer of the States as
required uoder the rules was obtaioed.

Sigoature & Desigoatoo of the Medical

Officer io charge of the case at the Hospital.

N.B. Certfcates oot applicable should be struck of.

COUNTERSIGNED

I certfy that the pateot ___________________________ has beeo uoder treatmeot at the AIIMS,
Bhubaoeswar (Odishas Hospital aod that the facilites provided were the mioimum which were esseotal for
the pateot’s treatmeot.

Place: Bhubaoeswar Sigoature of Medical Superioteodeot

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