FORMS AND CERTIFICATES

APPENDIX - II
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN
CONNECTION WITH MEDICAL ATTENDANCE AND TREATMENT OF GOVERNMENT
SERVANT AND THEIR FAMILIES
1

Name and Designation & Section (in block letters)

Office in which employee

Pay of the Govt., servant as defined in FR s and

others employments which should be shown
separately
Place of duty

4
5

Full Residential address with door No and Name of :

the Mohall
Name of the patient, His/Her relationship to the Govt., :
servant. In case of children state age also
Place at which the patient fell ill
:

Nature of illness and its duration

10

Details of amount claimed cost of Medicines

purchased from the market/List of medicines/cash
memos, and the essentiality certificate should be
attached each in duplicate signed by treatment
doctors
Total amount claimed

11

List of enclosures

: Rs.

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT/PENSIONER

I here by declare that the statement in this application is true to the best of my
knowledge and belief and that the person from whom medical expenses were incurred is a
member of my family as defined under the Government servant Medical attendance rules
1972and wholly dependent upon me.

Signature of Govt., Servant/Pensioner

and office to which attested

DECLARATION CERTIFICATE
I .(full name & Designation) here by declare that my Father/Mother,
Sri/Smt.. has no property or income of his/her own and that he/she is
wholly dependant upon me.

Station:

Signature & Designation.

Date:

EMERGENCY ADMISSION CERTIFICATE

This is to certify that Mr./Mrs./Ms..

S/o, D/o,

W/o.age about .. admitted in our hospital in .

Department under emergency on . at . Am/Pm.

The provisional diagnosis is

Signature and Designation of the

Attending Medical Authority.

CERTIFICATE - A
(To be completed in the case of patients who are not admitted to hospital for treatment)
1. I Dr. ... hereby certify that
(a)That I charged Rs... for...Consultation on
....at my consultation room/at the residence of the patient.
(b).

That I charged Rs....for administering intramuscular/

intravenous/ subcutaneous injections on (Dose to be given) at my consulting

room at the residence of the patient.
(c). That injections administrated repay in formatting or propyloction purpose.
(d).

That the patient has been under treatment at ..

Hospital/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..
...hospital and do not include proprietary preparations for which
cheaper substances of equal therapeutic values are available not preparations which are
primarily foods, tonics, toilets or disinfectants.
Name of the Medicine

Cost

(e). That patient is/was suffering from and is/was under my treatment
from ..
(f). That the patient was/not given prentation post treatment.
(g). That the X ray, laboratory tests etc, for which an expenditure of Rs.
Was incurred was necessary and was under taken on may active at the name
of the hospital or laboratory)
(h). That referred the patient of Dr. .for specialist mutilation and that
the necessary approval of Director, Medical Service as required under the rules was
obtained and
(i).

Date.

That the patient did not require/required hospital etc.

...

Signature
and
Designation
of the Authorized Medical attendant.

ESSENTIALITY CERTIFICATE
I Certify that Mrs./Mr./Miss . . . . . . . . . . . . . . . . . . .wife/son/Daughter of Mr. . . . . . . . . . .
. . . . . . . . . . . . . .. Employed in the. . . . . . . . . . . . . . . . . . . .. has been under my treatment for . . . .
. . . . . . . . . . . Deceases from . . . . . . . . . . to . . . . . . . . . . . . . .. . At . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . .. Hospital/my consulting room and that the under mentioned medicines
prescribed by me in this connection were essential from recovery/prevention of serious
deterioration the condition of the patient. The Medicines are not stocked in the . . . . . . . . . . . . . . .
. . . . . . . . . . . hospital (from supply to patients) and do not include proprietary preparations fro
which cheaper substance of equal therapeutic value are available or preparations which are
primarily foods, toilets or disinfectants.

Name of Medicines

Price

Signature and Designation of Authorized Medical

Attendant Signature of the Medical Officer In
charge in the case of the hospital.

ADVANCE CERTIFICATE
(Certificate to be furnished by the Medical Officer under Rule 6)
Certified that Sri/Smta member of the family of Sri/Smt
working as .in the office of. .. at .is suffering from
and that a sum of Rs (Rupees ..) on is necessary
as advance to cover the medical expenses reimbursement by Government in the case.

Date:
Place:

Signature
Designation

ADVANCE CERTIFICATE FOR SECOND TIME TREATMENT

(Certificate by Medical Officer under Rule II)
Certified that Sri/Smt a member of the family of
Sri/Smt..working as .in the office of the
at.. (Place) is still suffering from and that a further sum of
Rs. (Rupees.) only is necessary as advance to cover the
reimbursable medical expenses in this case as from this date

Date:

Signature

Place:

Designation.

Note: Strike off unnecessary portion when the certificate relates to the Government
employee himself.

CHECK LIST FOR SUBMISSION OF MEDICAL ADVANCE/REIMBURSEMENT

1
2
3
4

10

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12
13

Name of the Employee and Designation

Name of the Patient and Relationship with
Employee
Name of Decease
Whether Disease covered in G.O.Ms.No. 86 Fin &
Plg. Dated 01-06-0992 if so, admissibility
Certificates should be enclosed.
Whether the Patient has been refereed to
NIMS/SVIMS in case the disease is not covered in
G.O.Ms.No. 86 Dated 01-06-1992.
Whether the patient underwent treatment
Hospital is a recognized hospital as per Govt.
orders.
Whether the patient has been referred by
NIMS/SVIMS is case of treatment taken in the
hospital recognized.
If not referred by NIMS/SVIMS justified reasons
and nature of the urgency of obtaining treatment
in recognized hospital as per G.O. 175 H&M dated.
29-05-1997.
Whether enclosed estimation certificate in case of
advance/Essentiality Certificate in case of
reimbursement.
Whether bills have countersigned by concerned
Head of Department in NIMS/SVIMS in case of
Medical reimbursement.
Amount of advance/reimbursement required, in
case of reimbursement in various hospitals
separate station to be shown.
Whether the claim has been referred within (6)
months.
Remarks of recommending officer

:
:
:
:

:
:

Signature of the Recommending Officer