SOUTHERN RAILWAY GR3GZ5T(0Id) FORM OF APPLICATION FOR CLAIMING MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE ANDIOR TREATNENT OF RAILWAY SERVANTS AND THEIR FANILIES. (Railway Board's No.E50 M.E3i4G dated 27 August 1950 No. E53 M.E.1/40/3 17 caied December _ 1853) N.B. Separate form should be used foreach patient. 1 | a)Name end designation of Railway servant _(in block letters) |b) Ciess Office in which employed Pay of the Railway servant as defined in the existing, Rules, and any other emoluments, which should be shown _| Separately = Peal [4 [Piece of duty = 5. | Actual resident address ok & | Name of the patient and histher relalionship to the Raiway servant (NB. In the case of children state age 2ls0) [7 | Place at which the patientielil 8, | Dotails of the amount claimed 4. MEDICAL ATTENDANCE 1) | Fees for consultation indicating wal a) | The name and designation of the Medical officer | consulted and. the Hospital or dispensary to which attached | By | The number and dates of consultation and the fees ~_| paid for each consultaton ee cots Whether consultation were had at the hospital, ai the | consulting ‘oom of the Medical Cffcer or at the residence of the patient. Whether consultation were bad at the hospital, at the consulting room of the |__| Médical Officer or at the residence of the patient. | ii) Charges for Pathological, Bacteriological, Radiological or other similar tests undertaken during diagnosis indicating : * 2) Thename of the hospital or leboratory Where the tests were undertaken and t) Whether the fests were undertaken on the advice of the authorized medical attendant. IFso Gentficate to that effect Should be attached. CostofmedicinespurchasedfromtheMarcketket _ (lis medicines _cash_memos and the essentially ceric should be attached)ILHOSPITAL TREATMENT (Charges for hosrital treatment, indicating separately the charces for) i) Accommodation (State whether it was according to the status or pay Ifthe Govt servant and in cases where the accommodation is higher than the status of the Rly. Servant a certifcate should be atached to the effect that the accommodation to which he was eniited was not available) Ih Diot i) Surgical operation or madical treatment {iv) | Pathoiogical, Bacteriological, Radiological or other similar test indicating - 2) The name of the hosgital or laboratory et witich undertaken b) Whether undertaken on the advice of the Medical Officer in charge of the case at the Hospital. If so, 2 certificate to that effect should be attached. Wy | Medicines: W) | Special medicines {lstof medicines, cash memos, and the essentalty cetfcate should be attached) Ordinary Nursing vi vii_| Special Nursing, te, | (NWurses specially engaged for the patient state whether they are employed on the advice of | the Medical Offcerin-charge- of the case at the hospital or at fhe request of the Railway ‘servant or patient. In the3 former case a certificate from the Medical Officer-in-charge of the case and countersigned by the Medical Superintendent of the hospital shoud be tached) ix | Ambulance charges (State the journey to & fro from undertaken) = 3 ‘Any other charges eg. charges for electic ight, fan, heater, air conditioning etc, | | (Stete also whether the facies refered to are @ part ofthe facilities normally provided to all pationts and no cheice was ___|lefitothe patient) NOTE: 1. Ifthe teaiment was received by the Railway servant at his residence under Rus of he Sectelaly of State's service (Rellway services, cess. | medical attendance) Rules 1941 or rule $7 of the Medical Attendance and treatment rules, give particulars of such treatment and attach a cattiicate from the authorized medical attendance as recuired by these rules 2if the treatment was received at @ hospital other than a Govemment Hospital, necessary detais and the certifcate of he authorized Medical Attendant thal the requisite treatment was nct available in any nearest Railway or Government hospital should be furishes.Nl CONSULTATION WITH SPECIALIST Fee paid a specaiist ora Medical Officer olher than the authorized Medical attendant, indicating 2 | The name and designation of the specialist or Nedical Officer consulted and the Hospital to which attached b [Number ard dates of consultaions and the fee ccrarged for each consultation q C | Whether consultation was had at the hospital, at the Consulting room of the specialist or Medical Officer, of at the residence of the patient | 2 ¢ | Whether the Specialist or Medical Officer wae consuited on the advice of the authorized meq attendant and the prior approval of the Chief Medical Oficer ofthe Raiway servant wes ones 80,2 certificate to that effect should be attached s Total amount cialmed 10" | Ustofenciosures L DECLARATION TO BE SIGNED BY THE RAILWAY SERVANT hereby declaro that the statements in this epplication are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent up an me. Signature... Designation / Office Forwarded fo CMD/MAS together wit the enclosures for aranging reimbursement, as admissible Payment should be made to the emplyee_in cash in the presence of edie ee 7 orby cheque on the bank of No. Head of Department/Divisional Officer. Transmitted 0 RAO... seen si -Senetion is accorded tothe refund of @ SUM OF RSs RUPODS. 5 = ~ Vide column, ae s--sne chargeable to - Seas to eeeans HO. Rs... et Dr Rs. to, ‘A pay order forthe amount éravn in favour of the employee is enclosed to enable him to arrange payprent. Enel: ~ Chief Medical Officer No. Date : Ne I) Ths poe for salle sition peat O40, 3) Alotginaleeot kre xpesaes hese coLn 8 shoe subninec alin athe clan _ hed of Chae lyr. er fi eb havent en usher ne ret, ante cetese stony he eet chats sale sented, ‘sae yeteaen¢ ne anounaamed The requiston sia by he Arid Miz tardnee edb stashed ho resin wos esd as pila hon Be Ge Hepa speafd heamouse'n Ru 18 R wltou nin De sso wile cere 'W. Esonty cents mreepuctofapeclnednes puhase aut ee SugIeCD Pe Gon Hesplas sho be subrite inthe grescibed ‘eon VE neament was ovals at state che an Os. fe ena eeacnthre shad eins enable CO tocando poston vi) Rembuserenofchagesinsra nNon Riva Hop by CV Enplayes od he iynovos emt iss, Vi) Weapon eipoy te mainum f whch bondoc viloevete Ne sae ws CV Sate pve of Foinbronelt Of sen camps unde be ieG8 SRC/RG3IG268(0LD SOUTHERN RAILWAY Certificate granted to Shri. / Smt. \Wife/Daugiter/Son of Shri Smt employed the office of. eet cettnseravestseeraoneesue CERTIFICATI {Tobe completed inthe case of patints who ae not admitiod in the Hospital fr treatment) |, Dr... cee hereby cerify 4) thal the injections administered were /were not for immunization o° prophylactic purposes b) that the patient has been under treatment at... vsvsesre Hospital and that ‘he under-mentioned medicines prescribed by me in this conection were essential for the ‘ecovery! prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the oe Hospital (name of Hospital) for supply io private Patiants and do not include proprietery preparations for which cheaper substances of equal {herapeutic values are avaiable ior preparations which are primaily foods, tole’s of disinfectants. SLNO] Name ofmedienes ce Rs i a 3 = 5 <2 j aE, 5 ¢) that the patient isiwas suffering frOM 0... .u0.00s00n and istwas under my teatment from, oie Ai 4) that the patient istwas not given pre-prometional or post-natal treatment. ) that the X-ray, Laboratory tesis, etc, for which an experditure of Rs. fe AS ‘cured were necessary and wore undertaken ons my_— aioe abet 5 , (Name of Hospital or Laboratory) {) that | referred the patient fo Dr. E for specialist ‘corfsullation and that the necessary approval of the, one (name of the Dist, Medical Officer), 2s required under the rules was obtained £) thatthe patient did not require require hospitaliseion. Signature & Designation of the Medical Officer & the HospitallDispensary To which attached NOTE: Certficate not appicable should be struck off. Cerificate © is compulsor and must be filed by the Medical Officer in all cases Cetticate grated 0 Mrs/NMiss Wite‘Son/Daughter of Mr. employed intheCERTIFICATE-B (To be completed inthe ease of patents who are admitted to Hospital for treatment) PART A (To be signed by the Medical Officersir-charge ofthe cass inthe Hospital) 1,Dr a) that the patient wes admitted to Hospital on the advice offon my advise saat : (Name of Medical Officer) ') that the patient has been under treatment at sie and thet the under- mettioned Medicines prescribed by me in this connection were essential for the rezoveryiprevention of serious deterioration in the condition of the patient. The medicines are not stocked in th a eae (Name of the Hespital) for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapeutic values are available for preparations which are primarily foods, toilets of disinfectants. SLNo ] ‘Name of Medicines. Price Rs. iD 3 7 3 ©) that the injections administered were/were not for immunii ‘d) that the patient is/was suffering from. ‘under my treatment from... ie to. ) that the X-Ray, Laboratory test, etc. for which on expenditure of Rs. was incumed ‘were necessary and were undertaken on my advice a x (Name of Hospital or Laboratory) f) that I called in Dreseessenene Sean consultation & that the necessary approval of the. District Medical Officer) as required under the rules were obtained). ig oF prophylactic purposes seeveeeenesenserseand isis Signature of the Medieal Officer-In-Charge of the case at the Hospital Note: This does not apply in case under Rule 903(b} (1) R.! PART B T"eertify that the patient has been under treatment at the a hospital and that the service of special nurses, for which an expenditure of Rs... “was incurred vide bills and reesipts attached were essential for the recoveryipcevention of serious deterioration in the condition of the patiert nter signed 7 7 ‘Chief or the Principal or the | Signature of the Medical Officer in charge of | District Medical Officer a | the ease at the Hospital | Certify that the patient has been under treatment atthe Hospital and that the facilities provided were the minimum which were essential forthe patient's ‘eaument, Place: Date: Metical Superintendent -eHlospital NOTE: Certificates 201 applicable should be stuck off. Centifieate(d) is Compulsory and must be filled by the Medical Office in all cases wsPROFOMA FOR SUBMISSION OF CLAM FOR REINGURESEWENT IDF MEDICAL EXPENGES INCURRED SY RALWAY ENLOYEES FOR ‘AM AMOUNT N PRIVATE HOSPTTALNON RECOGNISED NSTITUTIONS 1. Name of Patient 2. Age 3. Name pfemployee 4. Designation and Office 5. Pay 6. Relationship to the employee 7. Name of Institution where treatment was taken 8. Date of Admission © 9. Date of Discharge 10.Date of submission of claim 11.Reason for delay , if delayed for more than 3 months 12. Type of medical emergency = 13.Was there no Railway/Govt. Facility to deal it, 14. Distance of the nearest Govt Hospital and whether Facilities available there , 15.Distance of Nearest Railway Hospital and whether Facilities available there. If not how far is the Railway Hospital with the facilities available 16. Distance of the Private hospital from residence/place of Illness where facilities available17.When was the Railway medical officer was Informed Of such admission 418. Did the patient take any tréatment before or after for The present sickness(f this existed before and if yes, when) 19. Total amount claimed (with breakup of charges) 20. ltemwise break of expenditure had the treatment ina Government hospital 21. Verbatim views of CPOREIMBURSEMENT CLAIM FORM. [Name of te Ralinayy Retd, employee (in BLOCK testers) Designation ofthe Railway? Rets. employee (ia BLOCK eters) Oifice and Station of employment PeyiLast Pay ofthe Rellway/ Reid. employee inciuding grate pay Residential address MIC/RELHS no. and issuing Authoity MIC/ RELHS regisered aH Univ Hospital Sxeee I (AjNamoe and age ofthe patient 1148) Patents celationship to the Rly/ Revd. employee II Detils of Indoor Treatreeat at Non Railway Institute Neme of Hospital: Date of Admission: Date of Discharge: Diagneeis: Amount of Total Hospital Sill (Attach Staied bil Whether Treapnent was ikea in Emergency: Are you a CTSE member (VN): 1N, Whether subse to any Heals Inswance Policy’ ot covered ude any rhe ealh scheme: yes, have you received any aricunt from insuecee company forthe weanent in qxestion. Give demilsifany on ‘separte sheet 9 paper. 'Y. Teta) Amount Claimod VI Detais of Rank account where Reimborsement arsount isto be ammoom> 2. Name of Bank , Ascount No, « Branch MICR Code 4. FSC Code VIL lise nto (Pen Tick he ocumers anche nd we msn document) Photocopy of MIC! RELHS card Esscotility com Emergency Cerificate by the No Rly Hospital Discharge Summary Original Bille of Hospi! Original Casi vouchers of Orugscoasumableyimpleas etc. if rslevant ‘Outer posch of Stent. pacemaker, Implants etc Any oer enclosure. (incase of many enclosures, write aumber of aiitional enclosures here and ach & separate shee: with detail) pmepap> DECLARATION TO RE SIGNED BY THE RAILWAY EMPLOYEE ‘ereby declare thatthe saiemen's in this aplication are tre to the best of my knowledge and belief and that the persor for ‘whom medical expesses were insured is wholly dependent upoa ma, 1 um eware thet misuse of medical flies o ‘miepresentation of any kind ean wtvact penal action including cancelation of MIC’ RELHS Card. {hereby Seclare tat tis is ‘my final claim and sell not eae sry claim in future lo Rly oF any ether health scheme in teapect to this treament epiende Dae Piece *in case the beneficiary has medical insurance poicy and Intend to make claim for the treatment in question then hie/site may mate claln 10 insurance company first ard then submit claim to Rly with documents, bills etc, atuested byinsurance company.wom RAILWAY (MEDICAL DEPARTMENT = ESSENTIALITY cuin EMERGENCY CERTIFICATE, | oxatity that SbrShrimati/Kumar/Kursar fae daughter / dependent relative of Shei / Shrimssi emplayed in Indian Railway as c ~ beepital and that the treatment as Gescribed in the attached Discharge Card No. e+ tod atacbed bills therbon were provided ue tm an emergency sitmation, testmeas for whlch could aot have beea delayed. I further certify that the teetmut provided was esseatially required, Signanure of the Modical Officer Jn charge ofthe case at the nop Tailway horpital with Name and Stamp/Seal Sigasture of Hospital In-charge or Awberized signatory with Seump/Scal