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    Medical-Bill-form-20210831152801

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    Medical-Bill-form

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    Medical-Bill-form-20210831152801

    Uploaded by

    er.levish
    15 views4 pages
    Medical-Bill-form

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    © © All Rights Reserved

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    Medical-Bill-form

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    15 views4 pages

    Medical-Bill-form-20210831152801

    Uploaded by

    er.levish
    Medical-Bill-form

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    OFFICE OF THE

    PRINCIPAL DIRECTOR OF AUDIT (Steel)


    RANCHI

    EXTRACT OF MEDICAL CLAIM

    SEPARATE FORM SHOULD BE USED EACH PATIENT

    1. Name of the Govt. Servant with


    designation and section in which :
    he/she working and pay drawn

    2. Residential address and the place :


    at which the patient fell ill.

    3. Name of the patient and his


    relationship to the Govt. Servant
    ( in the case of children state age also) :

    4. Name of disease and period of Medical


    Attendance and treatment as given
    in the essentiality certificate :

    ‘A’ FOR TREATMENT OTHER THAN AS IN PATIENT IN A HOSPITAL

    5. Name of the authorized Medical


    Attendant, Designation and Hospital
    to which attached :

    6. Fees paid to authorized Medical Attendant:


    (i) No. and date of consultation including Date Amount
    fees paid for each consultation.

    (ii) No. of Injections administered date


    and fees paid for each
    7. MEDICINES PRESCRIBED AND INCLUDED IN CERTIFICATE ‘A’
    (Details or Cash Memo in Block letters)
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _
    Bill No. Name of the Company Name of Medicines in Block letters Amount
    & Date and address and quantity purchased (Rs.`)
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _

    _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _
    TOTAL

    8. Radiology and other included in Certificate ‘A’ for payment of Rs…… ……….. No. and date of receipt on
    what amount.
    9. Other charges such as Ambulance charges etc. Rs……… ……………… ‘B’ TO BE FILLED IN THE CASE
    OF TREATMENT AS ON IN PATIENT IN HOSPITAL
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __
    10. Details of hospital stoppage
    Hospital Receipt No. and Date Amount
    (1)
    (2)
    (3)
    _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _
    11. Allocation of charges: 1. Medical Advance
    2. Nursing & Accommodation
    3. Diet
    4. Cost of Medicines
    12. Details of Medicines (to be filled in as directed in column 7)
    Total Amount ( In word) Rupees -------------------------

    DECLARATION TO BE SIGNED (IN FULL BY THE GOVT. SERVANT)

    I hereby declare that the particulars furnished above are correct to the best of my knowledge and
    brief and that the person from whom Medical Expenses are incurred in wholly dependent.

    Date Full Sign. of the Govt. Servant.

    For Official Use Only.

    Scrutinised and passed for Rs……………….

    Audit Officer (A)

    DY. Director (A)

    Dealing Asstt.
    MED-97

    Form of application for claiming refund of medical expenses incurred in connection with Medical attendance and / or
    treatment of Central Government servants and their families

    N.B.- Separate form should be used for each patient.


    ---------------------------------------------------------------------------------------------------------------------------------------1.
    Name and designation of the Government Servant (IN block letters )

    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---
    1. MEDICAL ATTENDENCE---
    (1) Fees for consultation indicating----

    (a) The name and the designation of the medical officer consulted
    and the hospital or dispensary to which attached.

    (b) The number and dates of consultations and the fee paid for each consultation.

    ( c) The number and dates of injections and the fee paid for each injection.

    (d) Whether consultation and /or injections were held at the hospital ,
    at the consulting room of the medical officer or at the residence of the patient.

    (II) Charges for pathological, bacteriological , radiological or other similar


    tests undertaken during diagnosis indicating -----------
    (a) The name of the hospital or laboratory where the tests were 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.
    (c) Costs of medicines purchased from the market
    (List of medicines, cash memos & the essentiality certificates should be attached.)

    II . HOSPITAL TREATMENT-----
    Name of the hospital. Charges for Hospital Treatment including separately the charges for-----
    (i) Accommodation
    (state whether it was according to the status or pa y of the Government servant
    and in case 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 continment …………………………………………..
    (iv) Pathological bacteriological, radiological or other similar test including--------------
    (a) The name of the hospital or laboratory at which undertaken.
    (b) Whether undertaken on the advice or the medical officer in charge of
    (c) the case at the hospital, if so a certificate to that effect should be attached.
    (v) Medicines…………………………………………………………………………………..
    (vi) Special medicines…………………………………………………………………………….
    (List of medicines, cash memos and the essentiality certificate should be attached)
    (vii) Ordinary nursing………………………………………………………………………………
    (viii) Special nursing i.e. nurses specially engaged for the patient. State whether they were employed on the
    advice of the medical officer in-charge of the case at the hospital or 1st he request of the Government
    servant or patient. In the former case certificate from he medical officer –in-charge of the case
    countersigned by the Medical Superintendent of the hospital should be attached.
    (ix) Ambulance charges ( state the journey – to and from undertaking)
    (x) Any other charges e.g. charges for electric light , fan, heater, air conditioning etc . State also whether the
    facilities normally provide to all patients and no choice was left to the patient.

    Notes:- 1. If the treatment was received by the Government Servant at his residence under rule 3 of the secretary
    of state (M.A.) Rules 1938 or rule 7 of the C.S. (M.A.) Rules 1944 give particulars of such treatment and attach a
    certificate from the authorized medical attendant as required by these rules.

    2. If treatment was received at a hospital other than a Government Hospital necessary details and the
    certificate of the authorized medical attendance that the requisite treatment was not available in any nearest
    Government 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) Whether consultation was held at the hospital, at the consulting room of the special at or medical officer
    or at the medicines of the patient.
    (d) Whether the specialist or medical officer was consulted on the advice of the authorised 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 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 which attached

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