Medical Proforma
Uploaded by
Shahaan ZulfiqarMedical Proforma
Uploaded by
Shahaan ZulfiqarMonth________________
APPLICATION FORM FOR REIMBURSEMENT OF MEPDICAL CHARGES IN RESPECT OF
SERVING/RETIRED GOVERNMENT SERVANT AND HIS DEPENDENTS.
PART-A
1. Name, designation, BPS of the serving/retired Federal Government servant Alive/Deceased)
Rab Nawaz,
Inspector Inland Revenue (BPS-16) RTO Multan.
2. Name of the patient and relationship with the claimant as dependent, as specified in rule 2(d) of the
Federal Services Medical Attendance Rules, 1990.
Mrs. Shahnaz Begum (Wife)
______________________________________________________________________________________________
3. Diagnosis of the patient
Diabetic/Magrine/AVN
4. Ministry/Division/Department/Office of the serving/retired Government servant at S.No.1.
Ministry of Finance/Federal Board of Revenue/RTO Multan
5. Vendor No. and PPO No. For retired Government Servant __________________________N.A__________________
6. List of medicines with quantity/hospital bill/laboratory and other diagnostic charges etc. for which reimbursement is
claimed through this bill (format attached).
PART-B
Certificates by Government servant (or member of his family in case of deceased Government servant).
Certified that:i)
The member of my family for whose treatment reimbursement has been claimed is wholly dependent
upon me.
ii)
The claim was not drawn before.
iii)
I shall have no objection to the recovery of any amount overpaid, if any, from my pay/pension
or otherwise.
Signature ________________________________
FULL NAME OF THE GOVERNMENT SERVANT
or (claimant family member in case of deceased)
RAB NAWAZ
(in block letters)
Dated: ________________
CERTIFICATE BY THE AUTHORIZED MEDICAL ATTENDANT
Certified that the medicines/drugs/hospitalization/clinical tests/examinations listed below were essential for the
recovery and restoration of the patient, Shahnaz Begum W/o Rab Nawaz.
2.
It is further certified that neither the medicines/drugs etc. nor their effective substitutes could be supplied from the
hospital/dispensary.
Signature __________________________________
Designation ________________________________
Official Stamp ______________________________
COUNTERSIGNATURES
Departmental Controlling Authority
Hospital Authority
Signature __________________________________
Signature __________________________________
Designation ________________________________
Designation ________________________________
Official Stamp ______________________________
Official Stamp ______________________________
M.Haider Khan/M.Cla.
S.#
No. & Date of
Bill/Cash Memo
1
2
3
4
5
6
7
8
9
10
643 dt. 2-9-2014
Name of the Chemist
Shop/Hospital/Clinic/
Dispensary
Makkah Medicos, Multan
Name of Drugs/Medicines with
Quantity/Details of Tests etc.
Amount
Mixtrad Insulin
Tab. Viglip M 50/1000
Cap. Sibelium 5mg
Tab. Hitop 50mg
Cap. Celbex 200 mg
Tab. Neoprox 500mg
Cap. Tramal Plus
Cap. Sante 2mg
Tab. Carsel 50 mg.
BD Syring Insuline 1cc
1992/1440/750/596/960/828/882/356/109/150/-
TOTAL
(Rupees:
(04)
(60)
(60)
(30)
(60)
(90)
(60)
(30)
(30)
(10)
8063/-
Eight Thousand Sixty Three only )
Signature________________________
RAB NAWAZ
Inspector Inland Revenue, RTO Multan
(Full Name of the Government Servant)
M.Haider Khan/M.Cla.
S.#
No. & Date of
Bill/Cash Memo
Name
of
the
Chemist
Shop/Hospital/Clinic/Dispensary
Name
of
Drugs/Medicines with
Quantity/Details
of
Tests etc.
Amount
1
2
3
4
TOTAL
(Rupees
Signature________________________
MUHAMMAD MUZAFFAR KHAN LASHARI
(Full Name of the Government Servant
M.Haider Khan/M.Cla.
S.#
No. & Date of
Bill/Cash Memo
Name of the Chemist
Shop/Hospital/Clinic/Dispensary
Azmat Medical Store Multan.
No.3061 dated
23-05-2011
-do-
-do-
-do-
-do-
-do-
-do-
TOTAL
(Rupees Nine Thousand Six Hundred & Thirty only)
M.Haider Khan/M.Cla.
Name of
Drugs/Medicines with
Quantity/Details of
Tests etc.
02 Insulin Humalog
Plain.
01 Insulin Humalog 50
X 50
1 X 100 Dis.Syringes
ICC insolin 100
Teststrip Optium
Glucometer.
Amount
Rs.3,060/Rs.2,700/Rs.1,200/Rs.2,700/Rs.9,630/-
APPLICATION FORM FOR REIMBURSEMENT OF MEPDICAL CHARGES IN RESPECT OF
SERVING/RETIRED GOVERNMENT SERVANT AND HIS DEPENDENTS.
PART-A
1. Name, designation, BPS of the serving/retired Federal Government servant Alive/Deceased)
___________________________________________________________________________________________________
2. Name of the patient and relationship with the claimant as dependent, as specified in rule 2(d) of the
Federal Services Medical Attendance Rules, 1990.
_________________________________________________________________________________________________
3. Diagnosis of the patient _______________________
4. Ministry/Division/Department/Office of the serving/retired Government servant at S.No.1. RTO, MULTAN
_________________________________________________________________________________________________
5. Vendor No. and PPO No. For retired Government Servant ____________________________________________
6. List of medicines with quantity/hospital bill/laboratory and other diagnostic charges etc. for which reimbursement is
claimed through this bill (format attached).
PART-B
Certificates by Government servant (or member of his family in case of deceased Government servant).
Certified that:i)
The member of my family for whose treatment reimbursement has been claimed is wholly dependent
upon me.
ii)
The claim was not drawn before.
iv)
I shall have no objection to the recovery of any amount overpaid, if any, from my pay/pension
or otherwise.
Signature ________________________________
FULL NAME OF THE GOVERNMENT SERVANT
M.Haider Khan/M.Cla.
or (claimant family member in case of deceased)
_____________________________________
(IN BLOCK LETTERS)
Dated: ________________
CERTIFICATE BY THE AUTHORIZED MEDICAL ATTENDANT
Certified that the medicines/drugs/hospitalization/clinical tests/examinations listed below were essential for the
recovery and restoration of the patient, _______________________
2.
It is further certified that neither the medicines/drugs etc. nor their effective substitutes could be supplied from the
hospital/dispensary.
Signature __________________________________
Designation ________________________________
Official Stamp ______________________________
COUNTERSIGNATURES
Departmental Controlling Authority
Hospital Authority
Signature __________________________________
Signature __________________________________
Designation ________________________________
Designation ________________________________
Official Stamp ______________________________
Official Stamp ______________________________
M.Haider Khan/M.Cla.
