CERTIFICATE "B" (To be filled in the case of patients who are admitted to hospital for treatment) Certificate granted to Mr./Ms/___________________________________ wife/son/daughter of Mr._______________________________________ employed in the -___________________ _______________________. PART "A" I, Dr. _________________________________ hereby certify :- (a) That the patient was admitted to hospital on my advice of________________________________________________________________ (Name of Medical Officer) (b) That the patient has been under treatment at ___________________________and that the undermentioned medicines prescribed by me in this connection ware essential for the recovery/prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the _____________________________________________. (Name of the Hospital) preparation for which cheaper substances of equal therapeutic value are available nor preparation which are primarily food, toilets or disinfectants. S.# Name of Medicines Price Rs. Ps. S.# Name of Medicines Price Rs. Ps. 1. 8. 2. 9. 3. 10. 4. 11. 5. 12. 6. 13. 7. 14. (c) That the injections administered were/were not for immunising or prophylactic purposes. (d) The the patient is/was suffering from _____________________ and is/was under my treatment from ________________ to __________________. (e) That the X-Ray, Laboratory test, etc. for which an expenditure Rs. _________was incurred were necessary and were undertaken on my advice at ________________________________________________. (Name of the Hospital or Laboratory) (e) That I reffered the patient to Dr. ______________________________ for specialist consultation and that the necessary approval of the ________________________________ as required under the rules was obtained. (Name of the Chief Administrative Medical Officer of the State) Signature and Designation of the Medical Officer-in-Charge of the case at the Hospital PART "B" I certified that the patient has been under treatment at the __________________________hospital and that the services of the special nurses, for which an expenditure of Rs. ___________________ was incurred vide bills and vouchers attached, were essential for the recovery/prevention of serious deterioration in the condition of the patient. Signature and Designation of the Medical Officer-in-Charge of the case at the Hospital COUNTERSIGNED __________________________ Medical Superintendent ___________________Hospital I Certify that the patient has been under treatment at the ____________________ hospital and that the facilities provided were the minimum which were essential for the patient's treatment. __________________________ Medical Superintendent ___________________Hospital N.B.:- Certificate not applicable should be struck off, Certificate "B" is compulsory and must be filled by the Medical Officer in all cases.
