M.P (Madhya Pradesh) Govt Medical reimbursement claim form

M.P (Madhya Pradesh) Govt Medical reimbursement claim form

Download Form 1

Medical reimbursement – EMPTY

I.AC-218 Med.Eng.

FORM 1

FORM OF APPLICATION

[See Rule8(1)]

(N.B-Separate form should be used for each patient)

 

1. Name and designation of the Government servant
2. Office in which employed
3. Pay of the Government servant as defined in the Fundamental Rules and any other emoluments, which should be shown separately
4. Place of duty
5. Actual residential address
6. Name of patient and his/her relation to the Government Servant (N.B. In the case of Children, state age also)
7. Place at which patient fell ill
8. Nature of illness and its duration
9. Details of the amount claimed
(1) Medical attendance –
(i) Fees for consultation indicating-
(a) The name and designation of the Medical Officer consulted and the hospital or dispensary to which attached
(b) The number and dates of consultations and the fee paid for each consultation.
(c) Whether consultation were had at the hospital, the consulting room of the Medical Officer or at the residence of the patient.
(ii) Charges of pathological, bacteriological, radiological or the other similar tests undertaken during diagnosis indicating.
(a) The name of the hospital or laboratory where the tests were undertaken, and
(b) whether the tests were undertaken on the advice of the authorised medical attendant and if so, a certificate to that effect should be attached
(iii) Cost of medicines purchased from the market   (List of medicines, cash memos and the essentially certificate should be attached)

 

 

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(2) Hospital treatment- Charges for the hospital treatment, indicating separately the charges for-
(i) Accommodation (State whether it was according to the status or pay of the Government servant and in cases where the accommodations is higher than the status of the Government Servant, a certificate should be attached to the effect that the accommodation to which he was entitled was not available.
(ii) Diet
(iii) Surgical operation or medical treatment
(iv) Pathological, bacteriological, radiological . or other similar tests indicating-
(a) The name of the hospital or laboratory at which undertaken; and
(b) Whether undertaken on the advice of the Medical Officer-in-charge of the case at the hospital. I so, a certificate to the effect should be attached.
(v) Medicines
(vi) Special medicines
(vii) Ordinary nursing
(1) Special nursing i.e., nurses specially engaged for the patient. State whether they were employed on the advice of the Medical Officer-in-charge of the Government servant or patient in the former case a certificate from the M.O.I/C. of the case and countersigned by the Medical Superintendent of the hospital should be attached.
(2) Any other charges, i.e., charges for electric lights, fans, heaters, air conditioning, etc. State also whether the facilities referred to are a part of the facilities normally provided to all patients and no choice was left to patient.   Note : If the treatment was received by the Government servant at his residence, give particulars of such treatment and attach a certificate from the authorised medical attendant.
10. Total amount claimed
11. List of enclosures

 

Declaration to be signed by the Government Servant

 

I hereby declare that the statements in application are true to the best of my knowledge and belief an d that the person for whom a medical expenses were incurred in wholly dependent

 

Dated ……………………..                                                                                                ……………………………………………

Signature of the Government Servant

and Office to which attached

 

 

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FORM II

FORM OF ESSENTIALITY CERTIFICATE

[See Rule 8 (2)]

 

A-In case of medicines not included in the priced Vocabulary of the Medical Stores Depot.

 

CERTIFIED THAT Shri/Shrimati/Kumari ……………………………………………………….. Son/Wife/Daughter of Shri ………………………………………. employed in ……………………… ……………………………….has been under my treatment from……………………………………. for……………………………….. (Name of disease) at the ……………………………………………….. hospital……………………………….as indoor/outdoor patient and that the under mentioned medicines have been prescribed by me in this connection. These medicines are not included in the priced vocabulary of the Medical Stores, nor are they preparations which are primarily foods, toilets of disinfectants. These medicines were absolutely essential for the treatment of the aforesaid patient.

 

Name of Medicines

(1)…………………………………………………………………………	………………………………………………..
(2)…………………………………………………………………………	………………………………………………..
(3)…………………………………………………………………………	………………………………………………..
(4)…………………………………………………………………………	………………………………………………..
(5)…………………………………………………………………………	………………………………………………..

 

Signature and designation of the authorized Medical Attendant/

Signature of the Medical Officer I/c of the case at the Hospital

 

——————–

 

B- In case of medicines included in the Priced Vocabulary of the Medical Stores Dept.

 

I Certify that Shri/Shrimati/Kumari…………………………………………..Son/Wife/Daughter of Shri– …………………………………..employed in the …………………………….has been under my treatment from ……………………………………to for…………………………..Name of the disease) at the ………………….hospital………………….as indoor/outdoor patient and that the under mentioned medicines have been prescribed by me in this connection. These medicines are included in the priced vocabulary of the medical stores and are out of stock/not available in the……………………………………….. hospital (they do not include any medicines proprietary or otherwise outside the aforesaid priced vocabulary nor. are the preparations which are primarily foods , toilets or disinfectants).

Name of medicines	PVMS No		Cost
(1)		(2)		(3)
(1)………………………………………………..		…………………………….		………………………………
(2)………………………………………………..		…………………………….		………………………………
(3)………………………………………………..		…………………………….		………………………………

 

P.T.O

 

 

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(1)	(2)	(3)
(4)………………………………………………..	…………………………….	………………………………
(5)………………………………………………..	…………………………….	………………………………
(6)………………………………………………..	…………………………….	………………………………
(7) ……………………………………………….	…………………………….	………………………………
(8) ……………………………………………….	…………………………….	………………………………

 

 

Signature and designation of the authorised Medical Attendant/

Signature of the Medical Officer I/c of the case at the Hospital

 

———————

 

C-In case of Insulin Treatment

 

CERTIFIED THAT Shri/Shrimati/Kumari ………………………………………………………………… Son/Wife/Daughter of Shri/Shrimati ………………………………………………………………………………….. has been under my treatment for diabetes at my hospital and that insulin prescribed by the ………………………………………………………………………………. was for treatment during the initial stage/in the hospital of the disease for which no reimbursement has been made extending over the period from …………………………….. the patient having developed complications necessitating hospitalisation.

 

 

Authorised Medical Attendant/

Medical Officer I/c of the case at the Hospital