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Medical Reimbursement Form 97 Guide

Form-97 is a medical reimbursement claim form for central government employees to claim refunds for medical expenses incurred for treatment of themselves or their families. The multi-page form requires information such as patient details, treatment location, hospital bills with itemized costs, consultations with specialists, total amount claimed, and documents like bills and receipts. It also includes instructions on requirements if treatment was received at home or a non-government hospital.

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Bharati Das
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1K views4 pages

Medical Reimbursement Form 97 Guide

Form-97 is a medical reimbursement claim form for central government employees to claim refunds for medical expenses incurred for treatment of themselves or their families. The multi-page form requires information such as patient details, treatment location, hospital bills with itemized costs, consultations with specialists, total amount claimed, and documents like bills and receipts. It also includes instructions on requirements if treatment was received at home or a non-government hospital.

Uploaded by

Bharati Das
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

Form-97

Form of application for claiming refund of medical expenses incurred in


connection with medical attendance and/or treatment of Central
Government servants and their families – For medical attendance/treatment
taken both from an Authorized Medical Attendant and Hospital.

1 Name & 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 of 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 amount claimed :

I Hospital treatment :

Name of the hospital :

Charges for hospital treatment, indicating separately :


the charges for

(i) Accommodation (state whether is 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 or medical treatment or :


confinement

(iv) Pathological, bacteriological, radiological or :


other similar tests, indicating:-

(a) the name of the hospital or :


laboratory at which undertaken
and
:2:
(b) whether undertaken or the :
advice of the medical officer in
charge of the hospital, if so , a
certificate to that effect should
be attached

(v) Medicines :

(vi) Special medicines :


(cash memos and the essential certificates
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 request of the
Government servant or patient. In the farmer
case a certificate from 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 electronic :


light, fan, heater, air-conditioning etc., state
also whether the facilities referred to are a part
of the facilities normally provided to all patients
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 CSMA Rules, 1994, give particulars 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 the Authorized medical attendant as requisite
treatment was not available in any nearest Government hospital should be furnished

II Consultation with specialist:- :

Fees paid to a specialist or a Medical Officer :


other than the authorized attendant, indicating.

(a) the name and designation of the :


specialist or Medical Officer
consulted and the hospital to
which attached

(b) number and dated 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
:3:
(d) whether the specialist or medical officer was :
consulted on the advice of the authorized
medical attendant and prior approval of the
chief administrative medical officer of the
state was obtained. If so, a certificate to that
effect should be attached.

9 Total amount claimed Rs. :

10 Less advance taken on Rs. :

11 Net amount claimed Rs. :

12 List of enclosures :

DECLARATION 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 dependant upon me.

Signature of the Government Servant


and Office to which attached
Date :
Place:
Check list for reimbursement of medical claims:

1) Medical Reimbursement Claim Form (Form-97).


2) Copy of Employee ID card/ Pensioner ID Card.
3) Certificate-B.
4) Copy of Permission letter (if any).
5) Emergency certificate in original (if any).
6) Discharge summary in original.
7) Final consolidated (abstract) bill in original along with detailed break up of hospital
bills in original.
8) Receipts in original of total amount paid to hospital/pharmacy.
9) Copy of pass book showing Account Number with Name and Bank details viz.,
Branch Name, IFSC code etc.
10) Copy of referral from the specialist / advice of the specialist (if any).

Note: Please prepare your claim in the same sequence as mentioned in the checklist.

Common questions

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Transparency and accuracy in medical reimbursements are ensured through a systematic process that requires detailed documentation at every step. This includes mandated declarations, certificates, receipts, and approvals from authorized medical personnel and administrative officers. The structured checklist for submissions further ensures that no necessary information is omitted, enabling precise verification of claims .

The medical claims process for Central Government employees requires a series of detailed verifications for hospital treatments and specialist consultations. For hospital treatments, it mandates submission of certificates verifying that accommodations were appropriate for the employee’s status, receipts, and medical officer confirmations for special nursing or ambulance services . For specialist consultations, it demands certification that these consultations were advised by an authorized medical attendant and received prior approval from the chief administrative medical officer, along with detailed receipts of consultations .

Reimbursement for electronic facilities like air conditioning during hospital treatment is contingent upon these being part of standard patient accommodations without optional choice involved from the patient or guardian. The application must distinguish these charges separately and declare them as a non-preferential service essential for patient care . This ensures only necessary expenses are reimbursed without room for personal luxury charges.

Submitting false information in a medical reimbursement claim can lead to serious consequences for a Central Government servant, potentially including disciplinary actions or legal consequences. The declaration part of the application requires the employee to attest to the truthfulness of the information, emphasizing the accountability and legal implications of false statements .

To file a reimbursement claim for emergency medical expenses, a Central Government employee needs to submit several documents, including the Medical Reimbursement Claim Form (Form-97), Employee ID card copy, original Emergency Certificate if applicable, original discharge summary, final consolidated bill with detailed hospital bills, and original payment receipts . These documents ensure the emergency nature and validity of the claims.

For ambulance services to be reimbursed, certification is needed when these services are used specially at the advice of a medical officer, particularly if not a standard provision. This certification should be provided by the medical officer in charge and countersigned by the Medical Superintendent of the hospital, ensuring the service was medically necessary .

For treatment expenses at non-Government hospitals to be reimbursed, the employee must provide a certificate from the Authorized Medical Attendant, confirming that the necessary treatment was unavailable at any nearby Government hospital . This certificate should accompany other documentation to qualify for reimbursement under the medical claims process.

The Chief Administrative Medical Officer plays a crucial role by approving specialist consultations for reimbursement eligibility. The process requires prior approval from them, ensuring that consultations outside the authorized medical attendants are necessary and sanctioned, making them eligible for claim submission . This oversight helps manage and verify the necessity of specialist care, preventing misuse of medical reimbursements.

The relationship between the employee and the patient for a reimbursement claim is verified through declarations where the employee states the patient's dependence on them, alongside providing the patient's name and relation in the application form. For children, additional verification includes stating their age . This helps confirm the eligibility of the patient for coverage under the employee's health benefits.

A certificate for special medicines or nursing is required to verify the necessity of these additional services, ensuring they are essential for patient care. This is documented by obtaining a certificate from the medical officer overseeing the case, which is also countersigned by the hospital superintendent. Such documentation must accompany the reimbursement application to validate the claim for special treatments .

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