37 154626/2020/0/0 HOO,O/o ADG(E)-(SZ) Rem: SL.No. Description Expenditure details Break up of Expenditure incurred for emergency treatment of ~ , station name is as follows. He was continued treat ment from and discharged from hospital on sl ‘Admissibility as per No | Nature of Claim | Actual Bill CGHS rate Remarks Signature of DDO154626/2020/O/o HOO,O/o ADG(E)-(SZ) 1 | Date & Time of occurance of em 2 | Nature of Diseases 3. | Distance of Private hospital/Nursing home at! which the treatment was taken from the where the patient ill 4 Distance of nearest Govt,/recognized hospital from then place where the patient ill 5 | Whether consulted AMA/Govt.Hospital before first aid © | Date of operation/treatment 7 | Whether the claimant is a CGHS beneficiary? 8 _ Amount claimed by Govt Servant Amount admissible as per CGHS scrutiny by Head of Kendra 10 | Difference(B.9) Signature of DDO 3839 154626/2020/0/0 HOO,O/o ADG(E)-(SZ) This is to certify that the medical claim submitted by Shri in respect of relation working at who ‘was admitted under emergency condition for (Disease ) at (name of hospital) on ( date) examined by me | wish to state that claim of Rupees is genuine and as per CGHS approved rates. And recommend for competent authority sanction Signature Hoo Above certificate along with all copy of bills corrected as per actual amount to be reimbursed in red ink countersigned by DDO long with dependency certificate to be sent