(1)

FORM 1

Form of Application For Medical Reimbursement

See nute$(t)
N.8.I...... SEPARATE FORM SHOULD BE USED FOR EACH PATIENT

1 . Name and designation of Govemment servant

(in block letters)
2. Ofiiceinwhichemployed
3. Pay of the Government Servant as defined in the
fundamental rules & anyother employment
which should be shown separately.
4. Placeofduty
5. ActualresidentialAddress.
6. Name of the patient and his / her relation to the
' GovernmentServant.
(N.8. ln the case of children give the following
information also)
1. Serial No. of child
2. Dateof birth
3. Totalof children
7. Place at which the patient fell i ll
8. Natureof illness and its duration.
9. Detailof the amountclaimed.

lrl MEDTCALATTENDANCE
q) Feesforconsultation indicating
(a) The name and designation of the medical
officerconsulted and the hospitalor '
dispensary to which attached.
(b) The number and date of consultation and
the fees paid foreach consultation.
(c) Whetherconsultation were had atthe
hospitalatthe consulting room of the medical
ofiiceroratthe residence of the patient.
(ii) Chargesforp6dogicatbacterk €ieal . :..............
radloloOi{! or otfer similartests under taken
. during diagnosis indieting.
(a) The name of the hospital or laboratory where
the testwere undertaken and.
(b) Whether the tests were under taken on the
advice of the authorised medicalattendent
and if so a certificate to that effect should be
attached.
(iii) Cost of medicines purchased from the market
(Listofmedicines cash memo &the
essentiality certificate should be attached)
 (2',)

lill HoSPITAL TREATMENT

Charges for hospital treatment indicating
separately the charges. or.
(i) Accommodation (state) whether was according
to the status or pay of the Government servant
and in casewnilnithe accommodation is higher
than the status of the government servanta
certificate should be attached to the effectthat
accommodation to which he was entilled was
notavailable.
(ii) Date

(iii) Surgical operation or medical treatment

(iv) Pathological, bacteriological orothersimilartests

indicating-

(a) The name of the hospitalorlaboratorywhich

undertaken and.
(b) Whether under taking on the advice of the
medical officer in charqe of the case at the
hospital if so a certificate to the effect should'
beattached.
.
(v) Medicines

(vi) Specialmedicine-
(List of medicines Cash memo and the
issentiality certifi cates should be attached.)
(vii) Ordinarynursing.
(viii) Special nursing i.e. nurses specially eng.aged. for
" ttie patient staie whether they were.employ-ed
on ddvise of the medicaloffiCer incharge of
hosoital or atthe request of the Govemment
Servant patient in th'e farmer case a certificate
from the M.O. 1/cof the case & countersigned by
the medical superintendent of the hospital be
attached.

(ix)
' ' Any other charges e. g. charges for electriclight
fan heater air conditioning etc. state also whither
facilities refiered to a partbf the facilities refiered
to a partof thefacilityhormally provided to all
patiilnt and no choice was last to patient.

Note- lf the treatment was received by the Govemment '... . .. .

Servant at his residence give particulars

of such treatmentand attached a certificate s'l
from the authorised medical attendant.

(x) Totalamountclaimed.
(xi) List of enclosures.

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statement in the application are trub to the best of my knowledge and belief &
that Person for whom medical expenses were incurred is wholly dependent upon me.

Date:
Signature of the Government Servant and Officer to which attached
 (3)

FORM TI
FORM OF ESSENTIALIY CERTIFICATE
1

See Rule 13 L?-)

A-ln case of medicines not included in the priced vocabulary of the medical Stores Depot.

hospital as an out door / in door patient and that the under

mentioned medicines have been prescribed by me in this connection these medicines are not included in priced

vocabulary of the Medical Stores nor are the preparations which are primarily foods toilets or disinfectants,
these medicines were absolutly essential for the treatment of the aforesaid patient.

NAME OF MEDICINES

sl. Name of the Medicines Quantity Cost

No. 1 2 3

I
10

11

12

13
,14

15

' CERTIFICATE
This is to certify the Medicines presented out of P.V.M.S. are essential to the patient

Signature and designation of the authorised

Medical bttendant Signature of the medical
officer 1/c of case at the hospital.
 (4)
B{N CASH OF MEDICINES INCLUDED IN PR]CED
VOCABULARY OFTHE MEDICAL STORES DEPOT

CERTIFIED THAT Shri / Shrimati / Kumari .............:;..................

SonMife/DaughterofShri..''......,'...,'............'...:.

patient and that the under men-tioned medicines have been prescribed by me in this connection these

medicines are in the priced vocabulary of the Medical Stores and are the out'of stock not available
the.............. hospital. They do not included any medicinds proprietor of

otherwise outside the aforesaid priced vocabulary not are the preparations which are primarily foods toilet
ordisinfectants.

sr. Name of the Medicines P.V.M.S. No. Cost

No. 1 2 3

:l

I
10

11

',2

13

14

15

Signature and designation of the authorised

Medical attendent Signature of the medical
officer 1/c of the case at the hospital.
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XXVI- 4e - B
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a
.GIi*BSGrISeAR'H sEffi8{-AttAT' '., ' :'-','
STATEMENT ACCOPADYINC THE CLAIIUS FOR AETMBURSEMENT OF
ilt:. r:i lrr '-i - !!' : !.i .: -" ..i,,lml**ngHrtB6iBl'r-:
t. Name, designation and tbe departocnt of the
Goverom:nt Servant. -:

2, La) Name. of*[e.ggtieat and lisl.hcr.relrtlor

wirh the Gcverhmcnt Servert.
(b) Ia case of children givc ihe fc lh,wing
is,formatrsn also : -
(i) Datc of binh
rii) Number in order of birth
riii) Total nunber of children
3. Residcntial address of the Governmeot Servant.
4. Nature aud duration of illness with specific dales.
5. List of mcdicires or scccunt of which
reirnbursement is claimcd, shoring 3-

S. No. Neme of ehop (ash Memo Non-availability Namc of medicioes

No. & datc Gcrtificate fo. and
date
(a) (b) (c) (d) (e) |..;

t-
-l
6. Name & desigratioa of the Medicat Officcr
who treated thc paticnt.
.7 Date on which Ce sh Mcmo & Bes. Ccrtificatc
were sigaed by Medical Officer aod countersi-
.gaed by Civil Surgeor.
g. D*tr of submissicr of the claim to thc Aaso.
-uets Branch
9. Total amount claimed.
Signsture of the Government Servant,
Departmenr
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