Central Medical Bill Forms ( Medical Claim & Reimbursement Form )

CENTRAL MEDICAL BILL

Form of Application for Claiming Refund of Medical Expenses Incurred 

In connection with Medical Attendant and/or Treatment

Of central Govt. servant and Their Families

1.  Name and Designation of the Government Servant……………………………………………

     (IN BLOCK LETTERS)

2. Pay of the Govt, Servants defined in the fundamental Rules and other emoluments which

    should be shown separately.                        Rs ………………….. P……………………..P.M.

3. Office in which employed ………………………………………………………………………..

4. Place of duty ……………………………………………………………………………………....

5. Actual residential address …………………………………………………………………………

6. Name of the patient and his/her relationship to the ……………………………………………

    Govt. Servant (N.B. in case of children, state age also) ……………………………………..

7. Place at which the patient fell ill …………………………………………………………………..

8. Details of the Amount 

    1. Medical Attendant

(1.) Fees of consultation indicating (a) the name & designation of the Medical            Officer consulted and the hospital or Dispensary to which attached	Dr …………………………………. ..C.s. Attached to dispensary
(b) the number and dates of consultation & the fee paid for each consultation	…………………………………………… Rs. 5/ for the first and Rs. 3/- Subsequent consultation - total Rs.
(c) the number and date of injection and fee for each injection	……………………………………………. Rs. 3/- for each
(d) Whether consultation and/or the injection were had at the hospital at the consulting room of the medical Officer or at the residence of patient	Total Rs ………………………………… Consulting Room of M.O.
(ii) Costs of Medicines purchased from the market (List of the Medicines Cash Memo & the Essentiality Certificate should be attached)	Rs………………………………………. Rs ……………………………………… (i) Essentiality Certificate with its true copy (ii) ……………………………. Cash Memos Nos …………………………………………..

9. Total amount claimed ………………….  

10. List of enclosures……………………..

Declaration to be signed by the Government Servant

I hereby declare the statements in this application are true and correct to the best of my

  

knowledge and belief and that the person for medical expenses incurred wholly depends upon me.

 

Signature 

Officer to which Government Servant attached 

Date……………....

 

(2)

Certificate granted to Mr.Miss./Mrs……………………………………… Son (Daughter/Wife) of ………………………………. employed in the office of …………………………………………… 

(To be completed in the case of patients who are not admitted 

to the hospital for the treatment)

         I, Dr. ……………………………....………………………………hereby certify that I charged and received Rs. ………………………… for …………………………………………………………………..... Consultation  on

      …..……………………………………………………….at my consultation room after Dispensary hours.

(B)        I, Charged & received Rs. ………………………………………. For administering ………………………....

       ………………………………….. Extra muscular injection ……………………. On …………………………… at

       my consulting room after Dispensary hours.

(C)  The injections administered was were not immunizing or prophylactic purpose

Name of Medicines	Price	Name of Medicines	Price

(D)  The patient has been under my treatment at my consulting room and that under mentioned medicines 

       prescribed by me in this connection were essential for the recovery of serious deterioration in the condition

       of the patient. The medicines are not stocked ……………………………………………………………..in the

       Dispensary/Hospital ………………….…………………………………….. for supply to private patients and do

       not include proprietary preparations for which cheaper substances of equal therapeutic value are available

       and preparations which are primarily food toilets or disinfections.

(E)  That the patient was suffering from …...……………………………………………………… and was under my 

       treatment from ……………………………………………………………. To ……………………………………….

(F)  That the patient did not require hospitalisation

(G)  That the hospital is recognised for the treatment of the Central Govt. Employees and members of their families

(H)  The treatment does not include the treatment of gum boil payarrons, gingivitis delirium and venereal diseases etc.

(I)   Treatment was not of prolonged nature.

(J)  I was not on leave during the period of treatment.

 

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