FORM OF APPLICATION FOR MEDICAL CLAIMS Med. 97-A Form of application for claiming refund of medical expenses incurred in connection with medical attendance/treatment of Central Government servants or their families for treatment in 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 of the amount claimed : 1. 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 (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 authorised medical attendant. If so, a certificate to that effect should be attached (iii) Cost of medicines purchased from the : ................. market (Cash memos and the essentiality certificates should be attached) II. Hospital Treatment Name of the hospital : ................. Charges for hospital treatment, 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 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 are employed on the advice of the medical officer in charge of the case at the hospital or at the request of the Government 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 fro - undertaken) (x) Any other charges, e.g., charges for : electric light, fan, heater, air-conditioning, et. State also whether the facilities referred to are a part of the facilities normally provided to all patients and no choice was left to the patient NOTE 1. - If the treatment was received by the Government servant at his residence under Rule 7 of the CS (MA) Rules, 1944, give particulars of such treatment and attach a certificate from the authorised medical attendant as required by these rules. NOTE 2. - If the treatment was received at a hospital other than a Government hospital, necessary details and the certificate of the authorised medical attendant 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 authorised 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 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 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 : Rs. 10. Less advance taken on : Rs. 11. Net amount claimed : Rs. 12. List of enclosures : ................. DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT I hereby declare that the statements 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. Signature of the Government servant and Office to which attached ESSENTIALITY CERTIFICATES CERTIFICATE 'B' (To be completed in the case of patients who are admitted to hospital for treatment) Certificate granted to Mrs./Mr./Miss ----------------------------------------------wife/son/daughter of Mr. -------------------------------------------------------employed in the --------- [To be signed by the Medical Officer in charge of the ............. ...... case of the Hospital] I, Dr ............ hereby certify - (a) that the patient was admitted to hospital on the advice of ........... (Name of the medical officer)/ on my advice; (b) that the patient has been under treatment at .......... and that the undermentioned 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 primarily foods, toilets or disinfectants; Name of medicines Price 1. .............. .............. 2. .............. .............. 3. .............. .............. 4. .............. .............. (c) that the injections administered were/were not for immunising or prophylactic purposes; (d) that the patient is /was suffering from .... and is /was under treatment from .... to ..........; (e) that the X-ray, laboratory tests, etc., for which an expenditure of Rs. ....... was incurred were necessary and were undertaken on my advice at ....... ....... (name of hospital or laboratory); (f) that I called on Dr. ......... for specialist consultation and that the necessary approval of the .......... (Name of the Chief Administrative Medical Officer of the State) as required under the rules, was obtained. Signature and Designation of the Medical Officer in charge of the case at the hospital PART B I certify that the patient has been under treatment at the ........ hospital and that the service of the special nurses for which an expenditure of Rs. ......... was incurred, vide bills and receipts attached, were essential for the recovery/ prevention of serious deterioration in the condition of the patient. Signature of the Medical Officer in charge of the case at the hospital COUNTERSIGNED Medical Superintendent ..... Hospital *I certify that the patient has been under treatment at the ............ hospital and that the facilities provided were the minimum which were essential for the patient's treatment. Medical Superintendent Place ........ ........ Hospital NOTE : Certificates not applicable should be struck off. Certificate (a) is compulsory and must be filled in by the Medical Officer in all cases.
