EXTRACT OF MEDICAL CLAIM (N.B.:- Separate form should be used for each patient. The form should be filled in neatly and legibly). 1. Name of the Government Servant together will :_____________________________________ Designation and Section in which he/she working :_____________________________________ and pay drawn. :_____________________________________ 2. Residential address and the place at which the patient :_____________________________________ fell ill. :_____________________________________ 3. Name of the patient and his/her relationship to the govern- ment servant (in case of children state age also). :_____________________________________ 4. Name of disease and period of medical attendance and Treatment as given in the Essentiality Certificate :_____________________________________ "A" For treatment other than as in patient in a Hospital. 5. Name of Authorised Medical Attendant and Hospital to :_____________________________________ Which attached. 6. Fees paid to Authorised Medical Attendant(Number and date of Authorised Medical Attendant Receipt). :_____________________________________ (I) Number and date of Consultation I_________________________ II___________________________ ____________________________III_______________________ IV__________________________ (II) Number of injections administered with dated I.M. Injections on ________________________ I.V. Injections on ________________________ Total Rs._________________ 7. Medicines prescribed and included in Certificate "A" (details of each memo). Amount Name of dealer and number and date of bill Name of medicines Rs. P. 8. Radiology and other tests included in Certificate "A" for payment of (I) _______________________________ Rs.______________________ (No. and date of receipt) (On what account) (II) _______________________________ (III) _______________________________ 9. Other charges (Such as Ambulance charges etc.) "B" To be filled in the case of treatment as in-patient in a Hospital) 10. Details of hospital stoppages for payment of (I) _______________________________ Rs.______________________ (No. and date of receipt) (On what account) (II) _______________________________ (IV) _______________________________ Less diet charges, if the official is drawing a pay of Rs. 100/- and above. 11. Allocation of charges : Medical Advice, Nursing and Accommodation, Diet, Medicine (if any) Total ___________________ 12. Details of medicines (to be filled in as directed in Column 7). Grant Total ______________ 13. Other Charges DECLARATION TO SIGNED (in full) BY THE GOVERNMENT SERVANT. I hereby declare that the particulars furnished above are correct to the best of my knowledge and belief. Full Signature of Government Servant Forwarded in original to Admn. Section for necessary action. Audit Officer/Sr. Audit Officer For Official use only Scrutinised and passed for Rs. _____________________ Audit Officer/ Sr. Audit Officer Joint Director/Deputy Director
