APPENDIX-VIII
Med – 97
FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES
INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE OR TREATMENT OF
CENTRAL GOVERNMENT SERVANTS OR THEIR FAMILIES FOR
TREATMENT IN A HOSPITAL
1. Name & Designation of the : ………………………………………
Government servant (in block letter).
a) Whether married or unmarried. : ………………………………………
b) If married, the place where wife/ : …………………………………………
husband is employed.
2. Office in which employed. : ………………………………………
3. Pay of the Govt. 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 Govt. Servant.
7. Place at which the patient fell ill. : ………………………………………
8. Details of the amounts claimed. : ………………………………………
I. MEDICAL ATTENDANCE : .………………………………………
II. HOSPITAL TREATMENT -
Name of the Hospital. : .………………………………………
Charge for hospital treatment Indicating
separately the charge for
i) Accommodation (State whether it : .………………………………………
was according to the status or pay
of the Govt. Servant and in cases
where the accommodation is higher
than status of the Govt. 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 indication.
a) the name or the hospital or : .………………………………………
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 certificates should be
attached).
vii) Ordinary nursing. : .………………………………………
..2/-
-2-
viii) Special nursing, i.e. nursing, 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 Govt.
Servant or patient. In the former case of
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 : .………………………………………
electric light, fan, heater,
air conditioning etc. State also whether.
III. CONSULTATION WITH SPECIALIST - : .………………………………………
Fees paid to a Specialist or a Medical
Officer than the authorised medical
attendant, indicating.
a) Name and designation of the Specialist : .………………………………………
or Medical Officer consulted and the
hospital to which attached.
b) Number and dates of consultations : .………………………………………
and fees charge for each consultation.
c) Whether consultation was had at the : .………………………………………
hospital, at the consulting room of the
Specialist or Medical Officer, or at the
Residences 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 effect should be
attached.
9. Total amount claimed. : .………………………………………
10. Less advance taken on. : .………………………………………
11. Net amount claimed. : .………………………………………
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
dependent upon me.
Date ………………... Signature of the Government
Servant and Office to which attached.
APPENDIX – XIV
ESSENTIALITY CERTIFICATE
CERTIFICATE – ‘A’
(To be completed in the case of patients who are not
admitted to Hospital for treatment)
Certificate granted to Mrs./Mr./Miss ________________________________ wife/son/daughter
of Mr. ________________________________ employed in the
_____________________________.
I, Dr. ___________________________ hereby certify:-
a) that I charged 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 injections on ______________(dates to be
given) at ______________ my consulting room/the residence of the patient;
c) that the injections administered were not/were for immunizing or prophylactic purposes;
d) that the patient has been under treatment at ___________________________ hospital/my
consulting room and that the under mentioned 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
preparation which are primarily foods, toilets or disinfectants.
Name of medicines Price
1. _______________________________ ____________________
2. _______________________________ ____________________
3. _______________________________ ____________________
4. _______________________________ ____________________
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 required/require hospitalization.
Signature of AMA/Designation of
Dated __________________ the Medical Officer and hospital/
dispensary to which attached
N.B. - Certificates not applicable should be truck off. Certificate (e) is compulsory and must
be filled in by the Medical Officer in all cases.
APPENDIX – XIV
ESSENTIALITY CERTIFICATES
CERTIFICATE ‘B’
(To be completed in the case of patients who are admitted to hospital for treatment)
Certificate granted to ………………...................................................................
Mrs/Mr/Miss…………………………………………………………………………………...
Wife/son/daughter of…………………… Mr………………………………………………….
employed in the………………………………………………………………………………...
PART – A
I Dr……………………………………….. hereby certify:-
(a) That the patient was admitted to hospital on the advice of …….…………………………..
name of the medical office) on my advice:
(b) That the patient been under treatment at ……………………………... and that the under
mentioned medicals prescribed by me in this connection were essential for the recovery/prevent
of serious deterioration in the condition of the patient. The medicines are not stocked in the
……………………………………….. (name of the Hospital) for supply to private patients and
do not include proprietary preparations for which cheaper substances of equal therapeutic value
are available or preparations which are primarily food, toilets or disinfectants.
Name of Medicines Price
1. ………………………………………….. ……………………
2. ………………………………………….. ……………………
3. ………………………………………….. ……………………
4. ………………………………………….. ……………………
(c) That the injections administered were/were not for immunizing or prophylactic purposes.
(d) That the patient is/was suffering from………………………………………….. and
is/was under treatment from ………………….. to ……………………..
(e) That the X-ray, laboratory tests etc. for which an expenditure of Rs………………/ was
incurred were necessary and were undertaken on my advice at…………………………….
(name of Hospital or laboratory).
(f) That I called on Dr…………………………………………………….. for specialist
consultation and that the necessary approval of the …………………………….…… (Name of
the Chief Administrative Medical Officer of the State) as required under the rules, was obtained.
Signature and Designation of the Medical Officer
in charge of the case at the Hospital
PART – B
I certified that the patient has been under treatment the ……………….……. Hospital and
that service of the special nurses for which an expenditure of Rs. ……………….. /- was
incurred, vide bills and receipts attached, were essential for the recovery/prevention of serious
deterioration in the condition of the patient.
Signature and Designation of the Medical Officer
in charge of the case at the Hospital
COUNTERSIGNED
Medical Superintendent ………………………………………………… Hospital.
I certify that the patient has been under treatment at the …………….………….….
Hospital and that the facilities provided were the minimum which were essential for the patient’s
treatment.
Place: …………………….. Medical Superintendent
..…………………………….. Hospital