FORM OF APPLICATIONS FOR MEDICAL CLAIMS

Med.97

Form of application for claiming refund of medical expenses incurred in connection with medical attendance and/or treatment for Central Government servants and their families - for medical attendance/treatment taken both from the Authorised Medical Attendant and a Hospital

1.

Name and 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. Medical Attendance -
     i)  Fees for consultation indicating -  

         a)   The name and designation of the Medical
                  Officer consulted and the hospital or
                  dispensary to which attached
           b)    The number and dates of consultation and
                   the fee paid for each consultation.
           c)    The number and dates of injection and the
                   fee paid for each injection.
           d)    Whether consultations and/or injections
                   were had at the hospital, at the consulting
                   room of the medical officer or at the
                   residence of the patient.

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      ii)  Charges for pathological, bacteriological,
             radiological, or other similar tests undertaken
             during diagnosis indicating-

             a)    The name of the hospital or laboratory
                     where undertaken; and
             b)    Whether the tests were undertaken on the
                     advice of the authorized medical
                     attendant. If so, a certificate to that effect
                     should be attached. 

 



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      iii) Cost of medicines purchased from the
              market(Cash memos and the essentiality
              certificate should be attached).		  :
      II Hospital Treatment.
            Name of the hospital  
            Charges for hospital treatment, indicating
            indicating separately the charges  for -
       i)  Accommodation (State whether it 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
                     at which undertaken, and
             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  
       viii)   Special nursing, i.e., nurses, specially
                 engaged for the patient. State whether they
                  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 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 from-
                 undertaken)      


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NOTE 1. - If the treatment was received by the Govt. servant at his residence under Rule 7 of the C.S. (M.A) Rules, 1944, give particulars of such treatment and attached 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 Govt. hospital, necessary details and the certificate of the authorized medical attendant that the requisite treatment was not available in the nearest Govt. hospital should be furnished.









 
     III.     Consultation with Specialist -
                 Fees paid to a specialist or a Medical Officer
                 other than the authorized medical attendant,
                 indicating -
                 a)    The name and designation of the
                        Specialist or Medical Officer consulted
                        and the hospital to which attached.
                 b)   Number and dates of consultations and
                        the fees charged for each consultation.
                 c)   wherever consultation was had at the
                        hospital, at the consulting room of the
                        Specialist or Medical Officer, or at the
                        residence of 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 hat effect
                       should be attached.                            



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NOTE 1. - If the treatment was received by the Govt. servant at his residence under Rule 7 of the C.S. (M.A) Rules, 1944, give particulars of such treatment and attached 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 Govt. hospital, necessary details and the certificate of the authorized medical attendant that the requisite treatment was not available in the nearest Govt. hospital should be furnished.









 
     III.     Consultation with Specialist -
                 Fees paid to a specialist or a Medical Officer
                 other than the authorized medical attendant,
                 indicating -
                 a)    The name and designation of the
                        Specialist or Medical Officer consulted
                        and the hospital to which attached.
                 b)   Number and dates of consultations and
                        the fees charged for each consultation.
                 c)   wherever consultation was had at the
                        hospital, at the consulting room of the
                        Specialist or Medical Officer, or at the
                        residence of 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 hat effect
                       should be attached.                            



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9. Total amount claimed  :
10. Less advance taken on  :
11. List of enclosure  :

              

DECLARATION TO BE SIGNED BY THE
GOVERNMENT SERVANT 

I hereby declare that the statement 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.

 

Dated.................                                                      Signature of the Government servant
                                                                                          And Office to which attached. 

 

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