eee {fret - 97 Ge) MED. 97 (A) ‘teste ceed wala ae sh ee of Seed Reed here rw af teed ad af a oF oe ea ke (srt es & fe) Form of application for clciming refund of medical expenses incurred in connection wth medicol ‘ttendance and/or treatment of Centrol Goverment servants and thelr famies (Fortreatmentin a Hosptiad = 4 goo ew V8 Seperate fem shou be ued foreach patent 1 weed ead oy om ae oe Cae eet a) Name and Designation of he Government servant in block eters) 2. fsa mica a wim #2 ZH NOtice in which employed 3 acap Bad Hon oh aad ine sae ae aa mt, CRs a fa @, oh aE rn @ are te eRe) Pay ofthe Government servant as defined inthe Fundamental . Rules ond any other emoluments, which shouldbe shown seperately 4_ aed eo waa / Proce of auty frat at erates cay Actual residential address Oat or om ke send wala oe Se ‘Name ofthe patient and hismner relationship tothe Government servant comm cre ft one won ea set 3a af Prd IN. Bin the Case of chicken, state age also 7,_2e va aaa aoe wer Place at which the patient fei 8a al zon a aba /Dotais af the amount claimed, eater a2 genay Hospital Weatment 3a =I JName of the hospital ret Foe 85 nt Prion wal nr ea Be AE Charges for Hospital ireciment. Indicating separately the charges for- 388 38 | Accomodation red Rb os edt waka net det a Bea 3 ap 8, ae 26h gt se sae x @ hs Pt see ds ara 3 re we eke Ee a, we Nea a «) (State whetnerit was according tothe status or pay of he Govemment servant and in case whore accomodation is higher then the status of e- the Government servants.c cerifcate should be attached!o1he effect that the accomodation fo which he was entitled wasnot available.) Lap /iet ween Bie pa a ote 5 Surgical operation or medical treatment for confinement Iv Rep-aes, tam-Aeter, Atenas ew OEY Ea ae 30 Pathological, bacteriological redologlcalrothersmlrtestsincicatng Co) scare a sadoren ta eee The name of he hospital or laboratory at which test undertaken Ca) waa whe eked at ene a racer A GU? a al 8 ae O- a CHT ‘whether those fest undertaken on he advice of the medical oficerin- charge of the case at the hospital, s0, a certiicate to that affect shouldbe attached. Vat Medicines Wi fit zat Special medicines asl at ad, arg cn abe greta say of ad) (Us of medicines. cash memos and essentially cortiicate should be: cttachec) vi araem sed/Ordinary nursing ‘ate sc ett fate aca a al cro as ae ob te ef 1g sat re secret a gat ade fener tent A ae 2 ot aA coved dot of spon ce egw at ard cee eh A RA ee amet sen aed mre ae ale sm UR, Fra Abe 35 a rae at et ‘Special nurshing. Le. nurses sbecialy engaged for the pationt State ‘whether they were:employed on the advice of the medical officer In charge ofthe case atthe hospital or ct the reques ofthe Government servant or patient. in the former case a cerificate trom the medical officer-in-charge of the case, counter signed by the Medical Superin fendent ofthe hospital should be attached.Co) copia at Cod A a a wea oh ow Be) “Ambulance charges State the jourey-to and from undertaker) 600 ate ga ad a oe ot ht, ce, Hee, TCH ard (ag of ed fr afters acre: aot aed wh ot & ate deh of fa geo ea aw aE | - Any other charges 8.9. chages for elect light, fon, heater. cconationing. ef. State also whether the foctiesnorrhaly provided {al patients nd no choice was eft to the patent. ‘Beira 1. onze ooh Be Rees Red Preamac 1936 & Bran 9 (ar 9 ae R ae ars wea alfa (WHO GO) wre, 1998) B se NOTES a de (fren Reed) Pore 194d & Bras 7. (7 3h Ao Ute (EHO LO) BG 194A) Hs aE we eT BeONA oka ‘Bes en eh gon el ah sn Pret & ae et Bae eka aes Ren ca ST 3G ERE ithe treatment wastecelved by he Goverment servant athisresconce under ule 3of he Secretary ofStater Service (MA) Rules 1938"ule7 of the CS. (M.A) Rules 194, give particulars of such treatment and attach @ cericate ftom the Guthorsed medical attendant asrecewved by these rues 2. eR geen end ace & ere Ph he a Ba set ers Ret & he ep Rennes GN AIT fe aes warn at ae Ped Bran vee ec ad ad . if teatment was recelved at a hospital other than a Government Hospitai necessary details and the cert. cate of the Guthorised medical attendent, that the requisite treatment was not available In any necrest Government hospital should be furnished TT feng & ent | CONSULTATION WiTH SPECIALIST: aig Romana 2 Re Frat te Re AN A cord oe & Pe and ht ake et rat ah we ot Fost pcid toa speci! ora mecicalofficerotherthon the authorsed medcolatiendentincicating- (3 Ra Rena an reer ed et eB ke crx Reg RASH Rt secret A ae B | : (0) The name anc designation ofthe speciast of medical officer consulted ond the hospital to which attached. (mR ae ake Porn cata ad cee er we he ceo fe Ret wha @ 21 (©) Number and dates of consultations and the fees charged for each consultation. (ay a cand, fates a Prd & cert we a Re 7, rect seen et Be 1 (©) Whether consutation washeld at the hospital. atthe consuting ‘a _r0omat the specials or medical officer or atthe residence of the patient. (eo) ea Rah ot Re-seal Ren he, a oh aft ae on um & ormehe Rea sted ape ath fhe wea ae ot nf a a, a a fe oni (2. Whether the specials or medical oficer was consulted on tho ‘achice ofthe authorised medical attendant and the prior op- proval ofthe Chit Adminisatve Medical Orficer othe State ‘wos obtained. Ifo, 0 certificate to that effect should be attached 9. Far Breet eae a gar &/ Total amount claimed, Bos. . . 10 ci OH 3a wt 121 Bois Loss advance taken on. . 1. a ef Ip zm Net croount cloimed zoiRs 12. aeva oH a Uist of enclosures [ex ahem we eordl afar wecare @2 /DECLARATIONTO BE SIGNED BY THE GOVERNMENT SERVANT eyez & hs eo ee, A ra he eos am Be fetes 2 Ave a fe me 8, we 22a afi By hereby declre tha! he statements inthis aplcation ore tus best of my knowladge and Bole and thatthe Person for ‘whom medical expenses ware Incurred I wholly dependent upon me. “ah waked eee aks Ba we ee ea FaIDte : Soro of ne Government seventendOricefowrichatlached