Form of medical reimbrushement claim




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FORM OF MEDICAL REIMBRUSHEMENT CLAIM (Outdoor)

Form of application claiming refund of medical expenses incurred in connection with medical Attendance and treatment of Central Government Servants and their families.




1.

Name & Designation of Govt. Servant ( in Block letters)

::

....

2.

Office in which employed.


::

C. E. Commtte., Chandigarh-1

3.

Pay of the Govt. Servant


::

Rs. ..... + ......... (G.P) + Allowances

4.

Place of duty.


::

............

5.

Actual residential address


::

H.No. ........... Sec ........., Chd.

6

Name of the patient and his/her relationship with the Govt. servant


::

Name :............, Re’ship: ........

Age. ........ years.



7

Place at which the patient fall ill


::

Chandigarh

8. MEDICAL ATTENDENCE::




a)

Fee for consultation indicating the name & designation of the medical officer consulted & the hospital or dispensary to which attached.


::

Rs. ....................
Dr............…..

Govt. Multi Specialty Hospital , Sector 16, Chandigarh.






b)

The number and dates of consultation & has fee paid for each consultation.


::

For …………….Rs. …………..

On …………………………….






c)

The number and dates of injection & the fee paid for each injection.

::

For …………….Rs. …………..

On …………………………….






d)

Charges of pathological or other similar test indicating amount and place of test.


::

For Lab Test, CT Scan & X Ray. Rs. ........../- on .............

9.

Cost of medicines purchased from the market.

::

Rs. ............/-

10.

Total amount claimed

::

Rs. ............00


11.

List of enclosures:

::

Cash Memo/Bills and Other Receipts.



CERTIFICATE

Certified that I .............. (name) employed in Customs and Central Excise Chandigarh -1 am not availing medical facilities and financial medical allowances in lieu thereof either for myself and or the member of family (other) source other than under the C.S.(M.A) Rules 1944.

:

Signature of the Govt. Servant
DECLARATION TO BE SIGNED BY THE GOVERMENT 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 me.



Date : Signature of the Govt. Servant

SANCTIONED/PASSED FOR RS ……………….



ACAO(P&C)


ESSENTIALITY CERTIFICATES CERTIFICATE (A)

I, Dr ................................ hereby certify:-

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

(b) that I charged and received Rs. ……Nil…………………….for administering ……………………. in the venous, intramuscular 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 immunizing or prophylactic purposes.



(d) That the patient has been under treatment at .................................... .hospital/ my consulting room 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 stocked in the .......................................... (name of hospital) for supply to private patients and do not included proprietary preparations for which cheaper substances of equal the aphetic value are available nor preparations which are primarily foods, toilets or disinfectants.


Sr.

Name of Medicine

Qty.

Price

1










2










3










4










































































































TOTAL

.

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

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

(g) That the Xray laboratory test etc. for which an expenditure of Rs ......../ was incurred was necessary and undertaken on my advice at................(name of the hospital or laboratory).

(h) 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.

( i) That the Patient do not required hospitalization.


Signature & Designation of the Medical

Officer With Stamp.


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