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Medical Reimbursement Appendix II Form

It concludes with a declaration by the applicant that the information provided is true and the patient is a family member dependent on the government servant as defined in the relevant rules.

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Subrahmanyasarma Mantha
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4K views2 pages

Medical Reimbursement Appendix II Form

It concludes with a declaration by the applicant that the information provided is true and the patient is a family member dependent on the government servant as defined in the relevant rules.

Uploaded by

Subrahmanyasarma Mantha
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Appendix II Form

FORMS AND CERTIFIATES

APPENDIX II FORM
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH
MEDICAL ATTENDANCE AND TREATMENT OF GOVERNMENT SERVANT FAMILIES.

1. Name and Designation & Section :

2. Office of the employee :

3. Pay the Govt. Servant as defined in FRs and :


other employments which should be shown
separately

4. Place of Duty :

5. Full Residential address with door No and name :


of the Mohalla

6. Name of the Patient his/her relationship to the :


Govt. Servant in case of children state age also

7. Place at which the patient fell ill :

8. Nature of illness and its duration :

9. Details of amount claimed, cost of medicines :


purchased from the market/List of
medicines/Cash memos, and the Essentiality
Certificate should be attracted each in
duplicated signed by treatment doctors

10. Total amount claimed :

11. List of Enclosures:

i. Check List ( ) x. Essentiality Certificate ( )


ii. Emergency Certificate ( ) xi. Discharge Summary ( )
iii. Consolidation Bills ( ) xii. Medical Cash Bill ( )
iv. Operation Notes ( ) xiii. Dependence Certificate ( )
v. Non-drawal Certificate ( )
vi. Referral Proceedings ( )
vii. Reports ( )
viii. Pension ( )
ix. Others ( )

DECLARATION TO BE SIGNED BY THE APPLICANT.


I hereby declared that the statement in the application is true to the best of my knowledge and belief and that the
person from whom medical expenses were incurred is a member of my family as defined under the government
servant Medical attendance rules 1972 and wholly dependent upon me.

Signature of Applicant.
Signature of forwarding authority
and office to which attested.

FORMS AND CERTIFIATES APPENDIX II FORM APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH M

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