FORM of Medical Reimbursement Claims

FORM OF MEDICAL REIMBURSEMENT CLAIM

  Form of application and claming refund of medical expenses incurred in connection with medical attendance and treatment of central government servants and their families.

N. B. Separates forms should be used for each patient and cases.

1. Name & Designation of Govt. Servant

  ( in Block letters)

2. Whether married.

if married, the place where wife/husband 

is employed

3. Office in which employed.

4.pay of the Govt. servant as defined in the 

fundamental rules & any other emoluments

which should be shown separately .

5. Actual residential address

6. Place of duty.

7. Name of the patient and his/her relationship

with the Govt. servant NB : In cash of children

state age also place when patient fall ill.

8.Nature of illness claimed.

9. Details of the amount claimed:

i) Fee for consultation indicating:

ii) The name & designation of the medical

officer consulted & the hospital or

 dispensary to which attached.

iii) the number and dates of injection &

the fee paid for each injection.

iv) the number and dates of consultation &

has fee paid for each consultation.

v) Whether consultation and injections were

had at hospital/army consulting. room of

 the medical officer or at the residence of

the patient.

10. Any other charges.

11. Cost of medicines cash memo & the consentially

certificate should be attached.

12. Total amount claimed Rs........................................

13. Net amount claimed Rs..........................................

14. List of enclosures:

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statement in the application are true to the best of my knowledge

and belief and the person for whom medical expenditure incurred is wholly depend upon

etc 

Date :

       Signature of the Govt. servant

        & Designation :

*********************************

ESSENTIALITY CERTIFICATES

CERTIFICATE (A)

 Certificate granted to

Mrs/Mr/Miss……………………………………………………

Wife/son/daughter of Mr…………………………………………employed in the

…………………………………….

 I, Dr……………………………………………hereby certify.

(a) that I charged and received Rs…………………………….for consultations on …………………………….(dated to be given) at my consulting room/a the resident of the patient.

(b) that I charged and received Rs. …………………………………………….  for administering

………………………………………………..  in the venous, intra-mescullar 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 immunising or prophylactic purposes.

(d) That the patient has been under treatment at………………….hospital/ my  consulting room and that the undermentioned medicines prescribed by me in this connection

were essential for the recovery / prevention of serious deterioration in the condition of the patient.  The medicines are not stocked in  the……………………….(name of hospital) for supply  to private patients and do not included properietary preparations for which cheeper sustences of equal the apeutic value are available nor  preparations which are primarily foods, toilets or disinfectants.

Sl No.   Name of medicines                          Qty.                                        Prices

 That the patient is/was suffering from…………………… and is/was under my treatment from ………………………………………to…………………………….

(e) that the patient is/was not given pre-natal or post-natal treatment.

(f) That the Xray laboratory test etc. for which an expenditure of  Rs……………… …………………  ………. name of the  hospital or laboratory.

(g) 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.

(h) That the patient did not required hospitalisation.

Signature & Designation of

the Medical Officer and

Hospital Dispensary to which

attached