APPENDIX - XI

ESSENTIALITY CERTIFICATES

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 ..................................................... (date to be given) at my consulting  room/at the
            residence of the patient.

    b)    That I charged and received Rs. ........................................................ for administering
            ..............................................intra-venous/intra-muscular/subcutaneous injections
           on .................................................... (date 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 the Hospital) for supply
           to private patients and do  not  include  proprietary   preparations for which cheaper
           substances of equal therapeutic value are available nor preparations which are prim-
           arily foods, toilets or disinfectants.

            Names of Medicines                                                             Price

    1.    ..............................................................             ..................................................................

    2.    .............................................................              ..................................................................

    3.    ..............................................................             ..................................................................

    4.    ..............................................................             ..................................................................

    e)    That the patient is/was suffering from .................................................... and  is/was
            under my treatment  form ......................................................................................... 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 were necessary and were undertaken on my advice at.....................

            ...............................................................(name of  hospital or laboratory).

    h)   That I referred the patient to Dr. ...................................................................................

           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 require/required hospitalization.

Dated ................................                           

                                                                     Signature and Designation of the 
                                                                     Medical Officer and hospital/ 
                                                                     dispensary to which attended

N.B:- Certificates not applicable should be  struck off. Certificate (e) is  compulsory and
           must be filled in by the Medical Officer in all case.