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Cover Note

The document is a cover note for medical treatment and investigation referrals, detailing patient information, treatment specifics, and financial aspects. It includes sections for remarks from various medical and command authorities regarding the quality of treatment and payment sanctioning. The document also outlines a list of medical tests and procedures with associated costs and requires signatures for validation.

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sudershanchugh
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3 views2 pages

Cover Note

The document is a cover note for medical treatment and investigation referrals, detailing patient information, treatment specifics, and financial aspects. It includes sections for remarks from various medical and command authorities regarding the quality of treatment and payment sanctioning. The document also outlines a list of medical tests and procedures with associated costs and requires signatures for validation.

Uploaded by

sudershanchugh
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

COVER NOTE

REMARKS OF SEMO/SMO/PMO

a) Treatment/Investigation were/were not carried out as referral


b) Quality of treatment Satisfactory/Not Satisfactory
c) Remarks /Recommendations (if any)

Sig
Date Signature

SANCTION OF STATION COMMANDER


 Sanctioned for payment of Rs.
 Not sanctioned
 Approved for payment of Rs.
 Forwarded for CFA Approval

Sig
Date (Strike out Inapplicable) Signature

REMARKS OF SUB-AREA CDRINDEP SUB-AREA CDR

Sig
Date Signature

REMARKS OF AREA CDR

Sig
Date Signature

REMARKS OF ARMY CDR

Sig
Date Signature

REMARKS OF VCOAS

Sig
Date Signature
COVER NOTE
1. Name of Patient: :…………………………………………………………….……………
2. ECHS Registration Number. :……………………………………………………………………………
3. Service no. Rank & Name :……………………………………………………………………………
4. Diagnosis : …………………………………………………………………………..
5. Treatment/Procedure/Test for which Referred :…………………………………………………………………………
6. Referral Serial Number : …………………………………………………………………………..
7. Date of Referral : ………………………………………………………………………….
8. Date of Admission : ……………………………………………………………………………
9. Date of Discharge : ……………………………………………………………………………
10. No of days Hospitalized : …………………………………………………………………………..
11. Emergency was informed within 48 Hours : …………………………………………………………………………..
12. Bill Number and date : …………………………………………………………………………..
13. Patient Category : …………………………………………………………………………..

[Link] Name of the Test/ ECHS Ref. Page No. Amount Net Amount Remarks
Procedure No claimed Amount Entitled Rs.
1 Cons. By Specialist
2 Revisit by Medical
3 Room Rent
4 Medicine & Cons
5 Lab Charges
6 ECG
7 Lab Charges
8 Physiotherapy
9
10
11

Rs :

Date…………………….
Place…………………….

Auth Signatory

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