Medical Reimbursement Application Form

NATIONAL INFORMATICS CENTREDepartment of Information TechnologyMinistry of communications and Information TechnologyGovernment of IndiaFORM OF APPLICATION FOR MEDICAL CLAIMS[Form of application for claiming refund of medical expenses incurred in connection with medical attendance/ treatment ofCentral Government Servants or their families for treatment in a Hospital.]1. Name and Designation of Government Servant :i) Whether married /unmarried :ii) If married the place where wifeis employed :2. Office in which employed :3. Pay of the Government Servant as defined in thefundamental rules and any other emoluments whichshould be shown separately4. Place of Duty :5. Actual residential Address6. Name of the patient and his / herrelationship to the Govt. servant :7. Place at which the patient ill :8. Details of the amount claimed :I) Hospital TreatmentName of the hospital charges for hospital treatment, :indicating separetely the charges for1. Accomodation[State Whether it was according to the status or pay of the Govt.Servant and in case of where the accomodation is higher than thestatus of the Govt. Servant a certificate should be attached to theeffect that the accomodation to which he was entitled was notavailable] :2. Dist :3. Surgical Operation or MedicalTreatment4. Pathological, Bacteriologicalradiological or other similar tests,indicating the name of the hospital orlaboratory at which undertaken5. Medicines6. Special medicines (cash memosand essential certificates) shouldbe attached.1/3:

NATIONAL INFORMATICS CENTREDepartment of Information TechnologyMinistry of communications and Information TechnologyGovernment of IndiaFORM OF APPLICATION FOR MEDICAL CLAIMS[Form of application for claiming refund of medical expenses incurred in connection with medical attendance/treatment of Central Government Servants or their families for treatment in a Hospital.]7. Ordinary Nursing8. Special nursing i.e., nurses speciallyengaged for the patients, state whetherthey are employed on the advice ofmedical Officer in charge of the case atthe request of Govt. Servant or patientIn the former case a certificate from theMedical Officer in chargeof the case and countersigned by theMedical Superintendent of the hospitalshould attached.9. Ambulance charges10.Any other charges e.g. charges forelectric light , fan, heater,air conditioning , etc state also whetherthe facilities referred to are a part ofthe facilities normally provided to allpatients and no choice was left to thepatient.Note:1 If the treatment was received by the government servant at the residence under rule 8 ofthe Secretary of state; s service (M.A) rules 1938or rule 7 of the C.S (M.A ) rules, 1964,give particulars of such treatment and attach a certificate that the authorized medicalattendant as required by these rules.2 If the treatment was received at a hospital other than government hospital, necessarydetails and the certificate of the authorized medical attendent that the requisite treatmentwas not available in any nearest government hospital should be furnished.II. Consultation with specialistFees paid to a specialist or a Medical Officer other thanthe Authorized medical attendant ,indicating1. The name and designation of the specialistor Medical officer consulted and thehospital to which attached.2. Number and dates of consultations and thefees Charged for each consultation3. Whether consultations was had at thehospital at the consulting room of thespecialist or at the residence of thepatient.2/3

NATIONAL INFORMATICS CENTREDepartment of Information TechnologyMinistry of communications and Information TechnologyGovernment of IndiaFORM OF APPLICATION FOR MEDICAL CLAIMS[Form of application for claiming refund of medical expenses incurred in connection with medical attendance/ treatment ofCentral Government Servants or their families for treatment in a Hospital.]4. Whether the specialist or Medical officer wasconsulted at the advice of the authorizedmedical attendant and the prior approval of theChief Administrative Medical Officerof the State was obtained. If so a certificate tothat effectshould be attached.9 Total amount claimed :10 Less advance taken on :11 Net amount claimed :12. List of enclosures :1. Prescription2. Medicine Bill3. Essentiality certificateDECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANTI hereby declare that the statement in this application are true to the best of myknowledge and belief and the person for whom medical expenses were incurred is whollydependant upon me.Date:Signature of the Government Servant and office to whichattached .CERTIFICATE REGARDING PURCHASE OF MEDICNEThis is to certify that No Government Fare Price shops/co-operative consumer store or depotsrun by the central /state Government or local bodies or any other organization recognized under theCo-operative Societies Act exist within a radium of 2 (two) Kms from my residence.Place Signature : DateName :Designation :3/3