Serer arias carrie Pa aor, Seer, Here feerers yor 19 we aura areraeia Sercse eed ofergel arrar ast 1) fant arma Agel ara fern sei 02) Farrar got gear aM aria 08) SH WaT g Ae sear Bas 04) rome are carey femrercaratr We tae 05) fami Stara / are tar 06) SIAN aerea Brera are 8, rae [ato fart TROT He oH? 09) aire oe 10) SE e/a Ta aT anerit Sonera afar : fat. Tar. Faeroe sae: fa 7H 4.4. Una ae 5 fe MM) Seas Gera weg ae 12) Tae / sarewitean eh mee BET Search ATT @) aarrht aromen aoa Sati %) vam oe ream a aut-(3)- DETAILS OF INFORMATON FOR MEDICAL REIMBURSEMENT CLAIM OF |.P SHRIASMT. INS.NO. INFORMATION TO FILLD BY I.M.P./ I.M.O. 01) Name of the I.P. Age. 02) Name of the patient. Relationship with I.P. 03) Name of the Dispensary / I.M.P.With \.P.attached 04) Period of indoor treatment : Days from: to. 05) Period of out door treatment: Days from : 7 to: 06) Full Diagnosis ( write in capital letters) : 07) Name & Address of the hospital Where patient had taken treatment. 08) Whether patient was referred by IMO/IMP to the specialist centre / Govt.if not give the reason. 03) Whether admission in ESIS nosp./ ~ Govt.hosp.was possible. 10) Whether the medicine as prescribed were available in service Dispensary / specialist centre. 11) Whether the prescriotion wer produced by |.P.in spl.centre /service dispy. 12) Name of the medicines purchased by LP. From shop. 13) Date of admission in hospital from: 14) Please mention the condition of the patient at the tir 2 of admission in the hospital 15) Date of operation in hospital 16) Date of discharge o hospital: 17) Whether the case huis been : Certified as an eme gency by Hospital authority.-(4)- 18) An Amount of 1. Hospital Bill Rs, Reimbursement Claim by |.P. 2. Investigation Rs, Charges. 3, Purchase of Rs, Medicine. 19) An Amount recommended 1.Bed harges Rs, as per G.R.NO.ESI./1187/ 864/CR/177/Med 3, datd.6.7.92 2. Medicine Rs, & Circular of A.M.O. 3. Investigation Rs, 4.Other charges Rs, Total 20) Wherther all Certificates, Vouthers , Bills have been certified by the prescribe authorities. 21) Wherther all stemped Receipts in support of payment in origina! attached:- 22) Whether the patient was taking treatment before the emergency private treatment. SIGNATURE & RUBBER STAMP. OF IMP / IMO COUNTERSIGNED BY IMP /iMO.(5) INFORMATION REGARDING REIMBURSMENT OF MEDICAL EXPENSES APPLICATION NOR. 01) Name of Patient Yr 02) O.P.D.Treatment Se 03) Date of Admission with time = 04) Referred by Dr, - 05) Date of Discharge S 06) Foolow-up (if recommended) - 07) Previous History : 08) a) Condition at the time of Admis: b) Provisional Diagnosis - 09) Date of operation = 10) Operation Note = 11) Details of treatment Given = 12) Final Diagnosis - 13) Condition at the time of discharge :- SIGNATURE & STAMP:(6) TO BE CERTIFIED BY HOSPITAL AUTHORITIES WHERE THE PATIENT WAS TREATED FOR THE INDOOR ILLNESS. Certified that the patient Shri / Smt/ Kum ...... age Years was admitted in hospital on + a.m./ p.m. and discharged on .. Patient was treated for .. At the time of admission the Condition of the Patient was unconscious/serious. His/Her_transfer/ admission at any E.S.1S. Hospital / govt.Hospital have seriously. Jeopartised his/her health rising his/her life. 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