HEALTH CARE AGENCY DOCTORS ON CALL REPORTING FORM: CATENGORIES A/B/C (PLEASE CIRCLE APPROPRIATE CATEGORY) en MONTH [NAMES (IN CAPITAL) a ie UNIT /LOCATION WORKED ——— FON CALL ‘ETON CALLITICK AS APPROPRIATE) — weekdays weekends/PH Dal ¥ 2 3 - = = = a WHERE THE TOTAL DO NOT AGREE WITH THE DETAIL THEN PROCESSING OF THE CLAIM WILL NOT BE POSSIBLE TO ENSURE ALL DETAILS [REQUESTED ARE PROPERLYU FILLED IN AND THAT THE FORM IS DULY SIGNED Certified that this dim Is correct tolmant-——————--——--—-----——-~ Past Title “Approved for payment by consultantin charge ; icsignature ame Date. ‘Counter approval (only necessary where the doctor claiming is the CIC or DG) CMO signature———————- naeoes Name wmnenemn annem Date mr ENDORSED BY HR —---—- Designation =———-- cs