Link banner
Tuesday, 14 November 2017
Adhoc Bonus order 2016 and 2015
LTC advance application form
Posted on 14/11/2017 at 20:39 HRS
Sunday, 12 November 2017
LTC Bill Form Final Bill PDF
Today Let me present
Sunday, 30 March 2014
Medical Claim FORM
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 |
[Check here to get help:]
implies the amount what ones draw.
Thursday, 27 March 2014
MACP PROFORMA -Checklist
PROFORMA
FOR FURNISHING INFORMATION FOR GRANT OF FINANCIAL UPGRADATION UNDER MODIFIED ASSURED CAREER PROGRESSION(MACP) SCHEME
1 |
Name(Shri/Smt) of the Officer |
|||
2 |
Designation |
Superintendent |
||
3 |
Date of Birth |
|||
4 |
Seniority List No |
Not available |
||
5 |
(a) Post to which recruited as direct |
Inspector |
||
|
(b) Date of joining |
12.03.1992 |
||
|
(c) Scale of Pay |
Rs.1640-60-2600-EB-75-2900/- |
||
|
(d) Pay in PB & G.P as on 01.01.2006 |
PB-2(7450-225-11500) GP-4600/- |
||
6 |
Whether he/she has been promoted to next higher grade |
Yes |
||
(i) Post to which promoted |
Superintendent |
|||
(ii) Date of Promotion |
05.03.2003 |
|||
(iii) Scale of Pay |
6500-200-10500 scale revised to 7500-12000/- on 21.04.2004 |
|||
(iv) Pay in PB & G.P as on 01.01.2006 and subsequent dates. |
PB-2(9300-34800) GP-4800 |
|||
7 |
In case he/she has not promoted till date, |
No. |
||
8 |
Due date of 2nd Financial Upgradation and grade pay thereof |
12.03.2012 (will complete 20 years) |
||
9 |
Due date of 3rd Financial Upgradation and grade pay thereof |
12.03.2022 (will complete 30 years) |
||
10 |
ACR Grading of the previous 5 years from the due date |
YEAR |
Grading |
|
Reporting |
Reviewing |
|||
11 |
Whether clear from vigilance angle on due date of MACP? State YES or NO |
Not available in Divnl. Office |
||
12 |
Whether his Integrity is beyond of doubt ? |
YES |
||
13 |
Whether any minor/major penalty imposed during the last 10 years. If so, details thereof. |
No |
||
14 |
Remarks |
NIL |
||