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NFC Chss 01 2022 1510

1. The document is an application for reimbursement of cost of medicines from the Government of India Department of Atomic Energy Nuclear Fuel Complex. 2. It requests reimbursement for medicines provided to an employee or their dependent and includes details of the employee, patient, treatment dates, hospital/doctor, and documents provided like prescriptions and bills. 3. The applicant declares that the treatment was necessary and exclusively for the stated medical issue, and that they understand consequences of simultaneous treatment for the same problem like claim denial or other actions.

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153 views

NFC Chss 01 2022 1510

1. The document is an application for reimbursement of cost of medicines from the Government of India Department of Atomic Energy Nuclear Fuel Complex. 2. It requests reimbursement for medicines provided to an employee or their dependent and includes details of the employee, patient, treatment dates, hospital/doctor, and documents provided like prescriptions and bills. 3. The applicant declares that the treatment was necessary and exclusively for the stated medical issue, and that they understand consequences of simultaneous treatment for the same problem like claim denial or other actions.

Uploaded by

srihari
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Annexure-A

Government of India
Department of Atomic Energy
Nuclear Fuel Complex
Application for reimbursement of cost of Medicines
Date: …………………..…

Pl. put tick mark (√): Homeopathy Ayurvedic Allopathy

To:
APO (CHSS), NFC, Hyderabad.
DETAILS OF EMPLOYEE & PATIENT
Employee Name Employee Status:
(Shri/Smt./Kum): (In-Service/Retired/Deceased)
Designation & EC No. Unit Name:
Hyderabad /
Basic Pay / Last Pay drawn: CHSS Availing from :
Vijayawada
Patient Name: Relationship with Employee:
CHSS No. of Patient: Validity of Patient CHSS Card:
Address: Mobile No.:
HOSPITAL/AMA DETAILS
Hospital Name/AMA Name: Doctor Name:
Treatment from Date: AMA Code:
Treatment to Date: Total Amount incurred:
THE FOLLOWING DOCUMENTS ARE ENCLOSED
S No Documents Yes/No
1 Non availability certificate (in case of Allopathy)
2 Prescription(s) copy
3 Cash Bills in original
4 Copy of CHSS card of the Patient
5 Bank passbook copy/Cancelled cheque or Copy (For retired employees only)

PRE STAMPED RECEIPT (FOR RETIRED EMPLOYEES) & DECLARATION

Received a sum of Rs.______________ (In words ____________________________________________)


from Accounts Officer, NFC towards reimbursement of the Medical claim submitted by the undersigned.

I hereby declare that the statements in this application are true to the best of my knowledge and belief and
further I declare that the treatment in Allopathic or in any other forms of medicine have not been taken for the same
medical problems during the period of treatment mentioned above. I know the consequences of taking treatment
simultaneously for the same medical problem, such as disallowing the claims and in addition any other action that
may be taken against me.

Signature of the Prime Beneficiary


Certificate granted to the above patient who was suffering from ______________________________ and
was under my treatment from ________________ to __________________ and the under mentioned medicines
prescribed by me in this connection were essential for the recovery/prevention of serious deterioration in condition of
the patient. The medicines are not stocked in my hospital for supply to private patient and do not include
proprietary preparations for which cheaper substances of equal therapeutic value are available not preparation which
are primarily foods, toiletries or disinfectants.

S No. Name of the Medicines Quantity Amount (Rs.)

Signature of the Doctor


and Hospital stamp

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