Regional Head Quarters - Southern Region, Chennai-27

(Fields marked * are mandatory) IP MEDICAL ESTIMATE Estimate I / II / II

(To be issued by the Hospital/Nursing Home for the purpose of extending medical credit facility
to AAI Official / AAI-Retired Officials / CISF Official)

1 Name of the Official*

2 Employee Number*
3 Designation / Department*
4 Scale of Pay
5 Basic Pay
Patient Details
(To be filled by the treating doctor)
6 Name of the Patient*
7 Age / Relationship to the employee* Years / Relationship :
8 Diagnosis*
9 Date of Admission*
10 Probable date of Discharge*
11 Details of Operation
(If any mention date and details)
APPROXIMATE EXPENDITURE (In Rupees)
(To be filled by the hospital Administrator)
Consultation / Specialist Charges
Pathological Charges
Bacteriological charges
Charges for similar test (if applicable, specify details)
Theatre charges (if applicable)
Cost of medicines
Room Charges* Rs. x No. of Days

ICU / CCU Charges-Rs. x No. of Days

(If Applicable)
Medical Equipment charges (If Applicable)
Consumables Charges (If Applicable)

Implants / Stents / Lens etc.

(If Applicable, specify Name and Amount for each item)

Others (if any, specify with details)

Total*
Signature :
Signature of AAI Employee* (Mandatory) Name :
(Dependents can sign if in case the employee is admitted)
Relationship :
Note: Hospitalization of the AAI employee or his dependents has to be intimated to AAI, RHQ/SR via mail to
medical-sr@aai.aero within 12 hrs of admission.
The Patient’s identity is verified as per the Medical Photo Identity Card issued by the Airports Authority of India.

Date : Treating Doctor’s signature* :

Hospital Seal* : Treating Doctor’s seal* :
 APPLICATION FOR EXTENSION OF MEDICAL CREDIT FACILITY

To,

The Regional Executive Director

Airports Authority of India
RHQ/SR
Chennai – 600 027

Sub :- Request for Extension of Medical Credit Facility

Sir,

I am/ my dependent is admitted in the under mentioned hospital for medical treatment. I
request you to kindly issue the credit letter for the treatment as per the estimate given by the hospital
authorities attached overleaf.

1. Name of the Patient :

2. Relationship to the official :

3. Name of the Hospital :

4. Estimated Amount :

5. If Retd Official, date of retirement :

6. Contact Mobile/Landline No. :

Thanking You,

Place : Employee signature :

Date : Employee Name :
Employee No. :
______________________________________________________________________________

FOR OFFICE USE ONLY

Recommendation of the Locum Doctor

Certified that the diagnosis and expenditure amount mentioned in the hospital estimate is verified and
recommended for Rs._________________ (in figures) Rupees___________________________
_____________________________________________________________________________
(in words).
Other Remarks if any:

Date: Officer In-Charge

(Medical Services)

Dependency verified with Service Records and

found in order/not in order

Signature of Manager(HR)
Signature of the Dealing Asst