Certificate granted to Mr/Mrs/Miss _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ wife/son/daughter of Mr. __ _ _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _ employed in the ----------------------------------------------------------------. CERTIFICATE 'A' (To be completed in the case of patients who are not admitted to hospital for treatment) I, Dr. ________________________ hereby certified- (a) that I charged and received Rs. __________ for consultations on ___________________(dates to given) at my consulting room/at the residence of the patient (b) administering _______________________________intra muscular subcutaneous injections on _____________________________________(dates to be given) at my consulting room/at the residence of the patient. (c) that the injections administered were not for immunizing or prophylactic purposes (d) that the patient has been under treatment at ___________ ____ ____ ___ _ _ _ hospital/ my consulting room and that the under mention medicines prescribed by me in this connection were essential for the recovery/preventions of serious deterioration in the condition of the patient. The medicines are not stocked in the _________________________________ (name of the hospital) . For the supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available no preparations which are primarily foods, toilets or disinfectants. Sl.No Name of Medicines Price S.No. Name of Medicines Price Rs. Paise Rs. Paise 1 9 2 10 3 11 4 12 5 13 6 14 7 15 8 16 (e) that the patient/was suffering from ___ __ ______ __ ______ ____ is/was under my treatment from _____________to ______________ (f) that the patient is/was not given prenatal or post-natal treatment. (g) that the X-ray, laboratory test, etc. for which an expenditure of Rs. _ _ _ _ _ _ _ _ _was incurred were necessary and were undertaken on my advice at _________________. (h) that I referred the patient to Dr._______ _________________ for specialist consultation and that the necessary approval of the (name of the Chief Administrative Medical Officer)__ ___ __ ___ __ ___ ____ _ __ _ _________ ____ ____ as required under the rules was obtained. (i) that the patient did not require/required hospitalization. Date .. Signature & Designation of the Medical Officer & the Hospital/Dispensary to which attached. Note: Certificates not applicable should be struck off CERTIFICATE (A) is compulsory and must be filled in by the Medical Officer in all cases. FORM OF APPLICATION CLAIMING REFUND OF MEDICAL CHARGES INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE OF THE CENTRAL GOVERNMENT SERVANTS AND THEIR FAMILIES. Note : Separate Form should be used for each patient. 1. Name and designation of Govt. servant (in Block Letters) ______________________________________ 2. Office in which employed -------------------------------------------------------- 3. Pay of the Govt. servant as defined in the FR and other Emoluments which should be shown separately ______________________________________ 4. Actual Residential Address ______________________________________ ______________________________________ 5. Palace of Duty ______________________________________ 6. Name of the patient and his/her relationship with Govt. Servant (in case of children age should be written) ______________________________________ 7. Place at which the patient fell ill ______________________________________ ______________________________________ 8. Medicines purchased from the market (list of medicines, Cash memos and essentiality certificate should be attached ______________________________________ 9. Total amount claim Rs.___________________________________ 10. Less advance taken Rs.___________________________________ 11. Net amount claimed Rs.___________________________________ 12. List of enclosures 1. Essentiality Certificate 2. Cash memos for Rs.______ 3. Prescription Slip in original DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT I hereby declare that the statement in the application is true to the best of my knowledge and belief and that person for shom medical expenses were incurred is dependent upon me. Signature of Govt. servant Office to which attached : Section :
