ABCDEFGHIJKLMNOPQRSTUVWXYZAAABAC
1
www.sahayam.in
2
FORM OF APPLICATION FOR CLAIMING REIMBURSEMENT OF MEDICAL EXPENSES OF GOVERNMENT SERVANTS AND THEIR FAMILIES
3
(Separate Form should be used for each Patient)
4
5
1.Name and Designation of Government Servant (In Block Letters):
6
2. Scale of Pay:
7
3Office in which employed :
8
4.Place of duty:
9
5.Residential Address:
10
6.i)Name of Patient and relationship of the Governement Servant to the Patient :
11
ii)If the patient is spouse of the employee State whether he/she is employed with details:
12
iii)If employed whether the declaration of non-receipt of the claim in any form is attached:
13
7.Place at which the Patient fell ill:
14
HOSPITAL TREATMENT
15
8.Whether hospitalised or not :
16
9. If hospitalised whether in Government Hopital or Private (Notifed Hospital and the name of hospital):
17
10.If hospitalised outside the State:
18
i)Whether the Patient was on duty:
19
ii)Name of Institution:
20
11)If on special treatment outside the State :-:
21
i)Name of Institution:
22
ii) Whether Certificate of Director of Health Services as contemplated in Rule 7 (a) is attached:
23
iii)Whether prior sanction of Director of Health Services has been obtained :
24
12)Last date of Treatment:
25
CHARGES :-
26
13)Details of amount claimed:
27
(List of Medicines, Cash Memos and Essentiality Certificate should be attached):
28
i)Treatment in Government Hospital Medicines:
29
ii)Treatment in Private Institutions :
30
(Bills to be Certified indicating Emergency of the case)
31
1)Charges for Medicines:
32
2)Charges for Treatment:
33
3) Charges for accommodation:
34
4)Charges for Laboratory Service:
35
5)Charges for Diet:
36
14)Total Amount claimed
(In Figures and in Words)		:
37
15)LIST OF ENCLOSURES :-
38
1)Essentiality Certificate
39
2).List of Cash Bills
40
3).Certificate of Medical Officers
41
DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT
42
I hereby declare that the statement given above are true to the best of my knowledge and belief and that the person for whom medical expenditure has been incurred is wholly dependent on me.
43
44
45
Place :
46
Date:
Signature of the Government Servant
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100