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Annexure - C Medical Reimbursement Claim Form For Outdoor Treatment

1. The document is a medical reimbursement claim form for outdoor treatment. It requests information such as the name, designation, and salary of the employee, as well as details of the patient and their relationship to the employee. 2. The form specifies that reimbursement is being claimed either for treatment from a Registered Medical Practitioner or from a P&T Dispensary. It then lists the medical expenses being claimed, including consultation fees, diagnostic tests, medicines, appliances, and special treatments, along with attached prescriptions and vouchers. 3. The employee is required to declare that the statements given are true and that the patient is wholly dependent on them. A medical certificate from the treating doctor

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Patiala Bsnl
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1K views

Annexure - C Medical Reimbursement Claim Form For Outdoor Treatment

1. The document is a medical reimbursement claim form for outdoor treatment. It requests information such as the name, designation, and salary of the employee, as well as details of the patient and their relationship to the employee. 2. The form specifies that reimbursement is being claimed either for treatment from a Registered Medical Practitioner or from a P&T Dispensary. It then lists the medical expenses being claimed, including consultation fees, diagnostic tests, medicines, appliances, and special treatments, along with attached prescriptions and vouchers. 3. The employee is required to declare that the statements given are true and that the patient is wholly dependent on them. A medical certificate from the treating doctor

Uploaded by

Patiala Bsnl
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ANNEXURE - C

MEDICAL REIMBURSEMENT CLAIM FORM FOR OUTDOOR


TREATMENT
1.
3.
5.
6.
8.
10.

Name of Employee:
2. Designation:
Reg. No.:
4. Staff No.
Salary (Basic Pay + DA)/Pension (as on 01-04--------):
Place of Duty:
7. Name of Patient:
Relationship with Employee:
9. Age:
Reimbursement claimed under:
11. HRMS No.
(Tick relevant box)

Treatment from RMP (as per Para 2.1.0)

Treatment from P&T Dispensary (as per Para 2.1.2)


12. Nature of illness:
13. Name of Doctor/Hospital:
14. Details of claim:
(Attach prescription, vouchers, etc. in duplicate)
________________________________________________________________________
Voucher No.
Amount
Consultation:
Diagnostics/Tests:
Medicines:
Appliances:
Special treatment (e.g. Physiotherapy, Yoga etc.):
Others:
____________
Total:
_____________
(Rupees -----------------------------------------------------------------------------------------)
__________________________________________________________________
Declaration:
I, hereby declare that the statements given in application are true to the best of
my knowledge and belief and that the person for which medical expenses are incurred is
wholly dependent on me.
(Signature of Employee)

Certificate granted to Mr/Mrs/Miss ___________________________________________


Wife/Son/Daughter of Sh. _______________ Employed in the ____________________

CERTIFICATE A
I doctor _____________________________________ hereby certify

(a) That I charged and received Rs. ______________ for consultation on


_____________________ at my consultation room /at the residence of the
patient.
(b) That I charged and received Rs. ____________________ for administering
Intramuscular / sbu coetaneous injections on ____________ 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
mentioned medicines prescribed by me in this connection were
essential for the recovery / prevention of deterioration in the condition
of the patient.
(e) The medicines are not stocked in the __________________________ for the
supply to prevent and do not include preparation which are primarily
foods, toilets and disinfectants.

________________________________________________________________________
_____________
(f) That
the
patient
was
suffering
from
_____________________________________and is /was under my treatment
from _______________________ to ____________________.
(g) That the patient is /was not given pre-natal or postnatal treatments.
(h) That the X-ray, Laboratory tests for which an expenditure of
________________ was incurred were necessary and were undertaken at
my advice at ______________________________.
(i) That I referred the patient to Dr. ________________ for special
consultation and that necessary approval of the _____________ required
under rules was obtained (Chief Medical Adm. Officer).
(j) That the patient did not require/ required hospitalization.

Dated

Signature and Designation of the Medical Officer,

And the hospital/ dispensary to which


attached.

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