A THAK: Medical Claim FORM

Mungboi Media::FORM OF MEDICAL REIMBURSEMENT CL

FORM OF MEDICAL REIMBURSEMENT CLAIMS

Form of application and claiming refund of medical expenses incurred in connection with medical attendance and treatment of central government servants and their families.
N.B. Separate forms should be used for each patient and cases.

1.	Name & Designation of the Government Servant ( in BLOCK LETTERS)		[ENTER NAME OF THE GOVERNMENT SERVANT
2.	Whether married , if married , the place where wife/husband is employed.
3	Office in which employed.
4	Pay of the government servant as defined in the Fundamental Rules & any other emoluments which should be shown separately.
5.	Actual residential address.
4 .	Place of duty.
7.	Name of the patient and his/her relationship with the government servant. N.B:- In case of children state age also place when patient fell 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 date 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 consequentially 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 Government Servant
		Designation:

ESSENTIALITY CERTIFICATES
CERTIFICATE(A)

Certificate granted to Mr. /Mrs./Miss. [Name of Patient] wife/son/daughter of Mr.[name of Govt.Servant] employed in the name of the office

I, Dr. [Name of the Doctor], hereby certify
(a)	that i charged and received Rs. [the amount of rupees] for consultation on [put the date(s) here] at my consulting room/ the resident of the patient.
(b)	that i charged and received Rs. [the amount of rupees] in the venous , intra-mascular subcutaneous injections on [date(s) to be given ] at my consulting room / resident 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 [ name of the hospital or 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 stock in the [name of the hospital ] for supply to private patient and do not included proprietary preparations for which cheaper substances of equal therapeutic values are available nor preparations which are primarily foods, toilets or disinfectants.

Sl.NO	Name of Medicines	Quantity	Prices

	Row	TOTAL

that the patient is suffering from, [Name of Disease], and is/was under my treatment from [start Date] to [end Date] .
(e)	that the patient is/was not given pre-natal or post-natal treatment .
(f)	that [the X-ray /Laboratory Test etc ] for which an expenditure of Rs. [the amount of rupees] has been incurred were necessary and were taken (under ) on my advice at [name of the Hospital or Laboratory] .
(g)	that i referred the patient to Dr. [Name of the Doctor] for specialist consultation and that the necessary approval of the [Chief Administrative Medical Officer of the State] as required under the rule were obtained.
(h)	that the patient did not require hospitalisation.
	Signature and Designation of the Medical Officer And Hospital /Dispensary to which Attached.

ESSENTIALITY CERTIFICATES
CERTIFICATE(B)

[ To be completed in case of patients who are admitted to hospital for treatment ]

Certificate granted to Mr. /Mrs./Miss. [Name of Patient] wife/son/daughter of Mr.[name of Govt.Servant] employed in the name of the office

PART-A

I, Dr. [Name of the Doctor], hereby certify :-
(a)	that he patient was admitted to hospital on the advice of [name of the medical office /on my advice] .
(b)	that the patient has been under treatment at [name of hospital etc. ] and that the under mentioned 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 stock in the [name of the hospital ] for supply to private patient and do not included proprietary preparations for which cheaper substances of equal therapeutic values are available nor preparations which are primarily foods, toilets or disinfectants.

Sl.NO	Name of Medicines	Quantity	Prices

	Row	TOTAL

(c)	that the injections administered [were not/ were for] immunising or prophylactic purposes.
(d)	that the patient is suffering from, [Name of Disease], and is/was under my treatment from [start Date] to [end Date] .
(e)	that [the X-ray /Laboratory Test etc ] for which an expenditure of Rs. [the amount of rupees] has been incurred were necessary and were taken (under ) on my advice at [name of the Hospital or Laboratory] .
(f)	that i call on Dr. [Name of the Doctor] for specialist consultation and that the necessary approval of the [Chief Administrative Medical Officer of the State] as required under the rule were obtained.

	Signature and Designation of the Medical Officer in charge of the Hospital /Dispensary as the case may be.

PART-B

I certify that the patient has been under treatment at the [name of the Hospital ] and that the service of the special nurses for which an expenditure of Rs. [the amount of rupees] was 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 incharge of the case , at the Hospital

COUNTERSIGNED
Medical Superintendent, [name of the Hospital ] Hospital
Certify that the patient has been under treatment at [name of the Hospital ] Hospital and that the facilities provided were the minimum which were essential for the patient's treatment.
Date : [Date ]
Place : [Place of the Hospital ]	Signature of Medical Superintendent, in the Hospital