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Proforma For Claiming Refund of Medical Expenses - 1 - Split - 1

This document is an application form for claiming a refund of medical expenses incurred for treatment of central government employees or their families. [1] It requests information such as the name and designation of the employee, details of the patient and their relationship to the employee, treatment location, expenses incurred including hospital accommodation, tests, medicines, and consultations. [2] The employee must provide receipts for expenses and certificates from medical officers to justify specialized treatment. [3] The form concludes with a declaration by the employee and essentiality certificates from medical staff to process the refund claim.

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Ajay Singla
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541 views5 pages

Proforma For Claiming Refund of Medical Expenses - 1 - Split - 1

This document is an application form for claiming a refund of medical expenses incurred for treatment of central government employees or their families. [1] It requests information such as the name and designation of the employee, details of the patient and their relationship to the employee, treatment location, expenses incurred including hospital accommodation, tests, medicines, and consultations. [2] The employee must provide receipts for expenses and certificates from medical officers to justify specialized treatment. [3] The form concludes with a declaration by the employee and essentiality certificates from medical staff to process the refund claim.

Uploaded by

Ajay Singla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Application form for claiming refund of medical expenses incurred in

connection with medical attendance/treatment of Central Government


servants or their families for treatment in a Hospital

1. Name and designation of Government Servant


(In Block Letters)……………………………………………………………

(i) Whether married or unmarried …………………………………………

(ii) If married, the place where wife/husband is


employed……………………………………….……………………….

2. Office in which employed

3. Pay of the Government servant as defined in the Fundamental Rules and any
other emoluments, which should be shown separately.

4. Place duty. ……………………………………………………………………

5. Actual residential address. …………………………………………………..

6. Name of the patient and his/her relationship to the Government


servant………………………
N.B.—In the case of children state age also.

7. Place at which the patient fell ill. …………………………………………….

8. Details of the amounts claimed……………………………………………….


________________________________________________________

I. Hospital Treatment ---

Name of the hospital …………………………………………………...


Charges for hospital treatment, indicating separately the charges for, --

(i) Accommodation (State whether it was according to the status or pay


of the Government servant and in cases where the accommodation is
higher than the status of the Government servant, a certificate should
be attached to the effect that the accommodation to which he was
entitled was not available)……………………………………………
(ii) Diet……………………………………………………………

(iii) Surgical operation of medical treatment ………………

(iv) Pathological, bacteriological Radiological or other similar tests, -


Indicating ----

(a) The name of the hospital or loboratory at which undertaken; and

(b) Whether undertaken on the advice of the medical officer in charge


of the case at the hospital. If so, a certificate to that effect should
be attached

(v) Medicines…………………………………………………………

(vi) Special medicines………………………………………………….


(Cash memos and the Essentiality Certificate should be attached)

(vii) Ordinary nursing …………………………………………………

(viii) Special nursing, i.e., nurses, specially engaged for the patient. State
whether they are employed on the advice of the Medical Officer in
charge of the case at the hospital or at the request of the
Government servant or patient. In the former case a certificate
form the Medical Officer in charge of the case and countersigned
by the Medical Superintendent of the hospital should be
attached…………………………………………………………….

(ix) Ambulance charges -------


(State the journey --- to and fro ----- undertaken

(x) Any other charges, e.g., charges for electric light, fan, heater, air
conditioning, etc. State also whether the facilities referred to are a
part of the facilities normally provided to all patents and no choice
was left to the patient..........................

Note 1. ----- If the treatment was received by the Government servant at


his residence under Rule 7 of the CS (MA) Rules, 1944, give particulars of such
treatment and attach a certificate from the Authorized Medical Attendant as
required by these rules.

Note 2. ------ If the treatment was received at a hospital other than a


Government hospital, necessary details and the certificate of he Authorized
Medical Attendant that the requisite treatment was not available in any nearest
Government hospital should be furnished.

III Consultation with Specialist -----

Fee paid to Specialist or a Medical Officer other than the Authorized


Medical Attendant, indicating ------

(a) the name and designation of the Specialist or Medical Officer consulted
and the hospital to which attached ……………………………..

(b) number and dates of consultations and the fees charged for each
consultation....................

(c) whether consultation was had at the hospital, at the consulting room of
the Specialist or Medical Officer or at the residence of the Patient; and

(d) whether the Specialist or Medical Officer was consulted on the advice of
the Authorized Medical Attendant and the prior approval of the Chief
Administrative Medical Officer of the State was obtained. If so, a
certificate to that should be attached…………….

9. Total amount claimed ………… …………… Rs.

10. Less advance taken on ……. ………… …………… Rs.

11. Net amount claimed ………… …………… Rs.

12. List of enclosures ………… ………… …………… Rs.

DECLARTAION TO BE SIGNED BY THE GOVERNMENT SERVANT


I hereby declare that the statements in the application are true to the best of
my knowledge and belief and that the person for whom medical expenses
were incurred is wholly dependent upon me.

Signature of the Government servant and


Office to which attached
Date ………………………….
ESSENTIALITY CERTIFICATE

CERTIFICATE 'A'

Under Central Service (Medical Attendance) Rules


(To be completed in the case of patients who are not admitted to hospital for treatment)

Certificate granted to Mrs./Mrs./Miss.____________________________wife/son/daughter of


Mr._______________________employed in the _______________________________
_______________________________________________________________________
______________________.

I, Dr.____________________________________________hereby certify ______


_________________________

(a) that I charges and received Rs._________________________for__________


consultation on __________________________________(dates to be given) at my
consulting room/at the residence of the patient;
(b) that I charged and received Rs.___________________for administering_____
__________________intravenous/intra-muscular/subcutaneous injection
on________________________(dates to be given ) at _________________my
consulting room/the residence of the patient;
(c) that the injection administered were not/were for immunising or prophylactic
purposes;
(d) that the patient has been under treatment at _______________________hospital/my
consulting room and that the undermentioned medicines prescribed by me in this
connection were essential for the recovery/prevention of serious deterioration in the
condition of the patient. The medicines are not stocked in the
_____________________(name of hospital) for supply to private patients and do
not include proprietary preparations for which cheaper substances of equal
therapeutic value are available nor preparations which are primarily foods, toilets or
disinfectants.

Names of medicines Price

1. ____________________________ ________________________

2. ___________________________ ________________________

3. ___________________________ ________________________

4. ___________________________ ________________________
-2-

(e) that the patient is/was suffering from_____________________________ and is /was


under my treatment from ______________________to ____________________;

(f) that the patient is/was not given pre-natal or post-natal treatment ;

(g) that the X-ray, laboratory test etc., for which an expenditure of
Rs._____________________________was incurred was necessary and were
undertaken on my advice at_____________________________(name of the hospital
or laboratory);

(h) that I referred the patient to Dr. _________________________for Specialist


consultation and that the necessary approval of the ___________________(name of
the Chief Administrative Officer of the State) as required under the rules was
obtained;

(i) that the patient did not require/required hospitalisation.

Signature of AMA/Designation of
the Medical Officer and Hospital
(Dispensary to which attached)

Dated:_____________________

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