ffjoH yd mqoa.

, yosis wk;=re rlaIK l%uh

ysulus b,a,qus m;%h ^w.%ydr&

Tnf.a yslu wod, jkafka

bosrsfhka ^& oukak'
rcfha fm!oa.,sl ore Wm;la weialkaKd yDo ie;alula ms<sld
frday,l frday,l

(SMS)

( )

^b,a,q m;%h msrug fmr f iu. we;s Wmfoia m;%sldj lshjkak'&

1' b,a,quslre ms<sno f;dr;=re()

1'1

ku() ^isxyf,ka& mQcH$uhd$ush$fukjsh( '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
uq,l=re iu. ku ^bx.%Sisfhka&()---------------------------------------------------------------

1'2

^Pdhd msgm; wuqKkak&

1'3

mqoa.,sl ,smskh ^bx.%Sisfhka&() '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

^isxyf,ka&()-----------------------------------------------------------------------------------

1'4

Wmka oskh() '''''''''''''''''''''''''''''''''''''''''''''''''

1'5

rl:k wxlh () rdcldrs''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 'mqoa.,sl''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

1'6

B-f,a ,smskh (-

2 /lshdj ms,sno f;dr;=re (2'1

;k;=r (-''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

2'2

Tn /lshdj lrk wdh;kfha ku iy ,smskh ()''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

2'3

fuu jifrA ia:dk udrejla ,enqf k fmr fiajd ia:dkfha ku yd ,smskh

'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
3 l,;%hdf.a f;dr;=re
3'1

cd;sl wxlh()

3'2

ku()'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

3'3

fiajd ia:dkfha ku iy ,smskh()''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

34

;k;=r (-''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

4' rCIK m%%;s,dN lrkafka ()Tng fyda l,;%hdg fkd k wod, fldgfia ^& fhdod lrkaak'
4'1

orejkag(

ujg(

mshdg(

4'2'1

Tyqf.a$wehf.a ku()'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

4'2'2

Tyqf.a$wehf.a Wmka oskh () ''''''''''''''''''''''''''''''''''' jhi '''''''''''''''''''''''' /lshdj'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

5 m%;sldr ms,sno ia;r (5'1

frda.h fyda Y,Hluh (-
5'2
wfmalaIs; ysl uqo, (-
6' nexl= .sKq ms,sn iaa;rh ()

^Tnf.a fm!oa.,sl nexl= .sKqu - cd;sl b;srs lsrSf nexl=j " uyck nexl=j " ,xld nexl=j " im;a nexl=j " fldurAI,a nexl=j" fi,dka
nexl=j "yegka keIk,a nexl=j " fkaIka g%ia nexl=j " cd;sl ixjraOk nexl=j " mEka tAIshd nexl=j " fydxfldx weka Iekayhs nexl=j
iagEkav pdg nexl=j hk nexl=j,g wh;a .sKqula h hq;=h&

5'1

nexl= .sKq i|yka Tnf.a ku(- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

5'2

.sKq wxlh

5'3
nexl=f ku(- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' nexl= YdLdj(- ''''''''''''''''''''''''''''''''''''''''''''''''''
7' fuu whm;g wod, ho fjk;a wdh;khlska m%;smQrAKh lr ;sf k fyda whlr ;sf k
7'1 wdh;kfha ku iy ,smskh (-

7'2 f.jq uqo, (-

7'3 ysl wxlh$fhduq wxlh (-
8' w.%ydr rlaIK l%uh hgf;a Tn ,ndf.k we;s m%;s,dN ms,sno ia;r
ysl j.h

osskh

,enQ uqqo,

weia lKaKdvs

ore Wm;a

fjk;a frda.$
ie;al

9' whlref.a m%l%ldYh

by; ioyka f;dr;=re i;H yd ksjros nj;a" fuu ysslmEu by; 07 fcaohg hg;aj fjk;a rlaIK wdh;khlska"
fjk;a l%uhla u.ska fyda ta ioyd b,a,Sula bosrsm;alr fyda fkdue;s nj uu fuhska iy;sl fj'
udf.a l,;%hd iska fyda f fjkqfjka lsisoq rlaIK m%;s,dNhla ,nd fyda b,a,Sula bosrsm;a lr fkdue;s njg;a uu iy;sl fj'
rdcH mrsmd,k pl%f,aLk wxl 12$2005 ys 08" iii j.ka;sh m%ldr jHdc f,aLK bosrsm;a lsrSfuka yslmdkq ,nk ks,OdrShd
jeroslrefjl= jqjfyd;a wdh;k ix.%yfha ii lKavfha XLViii jeks mrsfPaofha Odk yd oKavkS;S ix.%yfha Odko wkqj
l%shd lrkq ,nk nj uu oks'
ysl f.u wxl 06 hgf;a i|yka nexl= .sKqug ner lrk f,i b,a,d is'

oskh

whlref.a w;aik

" " fld<U 10"

oqrl:k wxl ( 0114)873901)5

wka;cd,h ( www.nitf.lk
B,a ( mail@nitf.lk

*elaaia () 0114 ) 702667

10' wdh;k m%Odksshf.a iy;slh (uf.a wxlh (

by; ia;r ioyka uy;d$uy;ahf.a rlaIK yslu wjYH lghq;= ioyd ksfoaYlr
f iu. bosrsm;a lr' by; ioyka f;dr;=re i;H yd ksjros nj;a " Tyqf.a $wehf.a fm!oa.,sl ,smsf.dkqj wkqj
iy;sl lr' rlaIs;hd m%;sldr ,en frdayf,ka neyerjq udihg fmr udih jq udifha odhl uqo,
whlr nexl=f .......................YdLdf wxl ...................... orK fplam;ska cd;sl rlaIK
Ndr wruqof,a uyck nexl=f /csk YdLdf 033-2-001-2-2467951 orK .sKqug nerl< remsh,a ....................... l uqM
uqo,g we;=,;a lr we;'
w;aik .......................
ku .
;k;=r
oskh .......................

^ks, uqj ;eu w;HjYHhhs&

11' frda.shdf.a ffjoHjrhd$Y,H ffjoHjrhd iska imQQrAK l< hq;qh'

Should be filled by the Medical Officer/Surgeon of the patient.
11'1
11'2

11'3

11'4

frda.shdf.a ku
Name of the Patient :..
frda. ksYaph
..
Diagnosis of disease:..
....
idudkH rdcldrS lghq;= j, ksr;ug fkdyels ld, iSudj (- .osk
isg..osk olajd
Period unable to attend to usual business/works:
From:-. To-.
frday,g we;=,;a l, oskh (-.
msgjq oskh (-
If admitted to the hospital, Date of admission..
Date of discharge..

by; ioyka frda.shdf.a ffjoHjrhd$Y,H ffjoHjrhd ud nj;a" fuu b,a,Su inkaOjQ fiajdj uu wkqu; l,
nj;a iy;sl lr'

frda.shdg m%;sldr l, ffjoHjrdf.a$

fYaI{ ffjoHjrhdf.a w;aik yd ks, uqdj
oskh (-
I hereby certify that I am Medical Officer/Surgeon of the above named patient and approve
submission with regard to this claim.
Date

whm; imQrAK imQrQrAKAK lsrsrSuSu i|yd Wmfoia

Signature of Medical Officer/Surgeon

^fmdararu wxl A I frday,a .; yd ie;al " yDo ie;al " ore Wm;a" weia lKaKdvs"s" ms<sld jl=.vq wdoS frdaa. j,g wod, ysl
b,a,q lsrsSu i|yd muKs's's'&
1'
2'
3'
4'

frday,ska msg osk 90 we;=,; ysl whoqm; cd;sl rCIK Ndr wruqo, fj; fhduq l, hq;=h'
Tn wmfj; fhduq lrk iEu ,sms f,aLkhlu cd;sl yekqm;a wxlh meyeos,sj" ksjerosj ,su w;HjYHf'
,smsf,aLKj, Pdhd msgm;a bosrsm;a lrk iEu gu wdh;k m%Odkshd iska tajd iy;sl l, hq;=f'
iajdmqreIhd " NdrAhdj" fofokdu rlaIs;hka k
w' ysl m; frda.shdjq rlaIs;hdu bosrsm;a l, hq;=hs'
wd' idudcslhdf.a orejka fjkqfjka ysl b,a,q l, hq;= jkafka tla wfhl= muKs'
5'
hefmkakka i|yd ysl wh]m;a bosrsm;a lsrSfoS my; f,aLk j, iy;sl l, cdhd msgm;a th hq;=hs'
rCIs;hd jdyl k

w' l,;%hd i|yd - jdy iy;slfha Pdhd msgm;la

wd' orejka i|yd - Wmamekak iy;slj, cdhd msgm;a
^orejd - jhi wjqre 21 g wvq wjdyl /lshdjla fkdlrkafkl= h hq;=hs&
rCIs;hd wjdyl k
rCIs;hdf.a uj$mshd i|yd - ^uj$mshd - jhi wjqre 70 g wvq h hq;=hs&

rCIs;hdf.a Wmamekak iy;slfha cdhd msgm;a

ujf.a $mshdf.a Wmamekak iy;slfha fyda cd;sl ye\kqmf;a cdhd msgm;la
wjdyl nj oekaug wdh;k m%Odkshdf.a ,smshla
ujg$mshdg ;ukaf.ka hefmk njg yd Tjqkag lsis\ wdodh udrA.hla fkdue;s njg
.%du fiajd iy;slhla m%dfoaYSh f,alf.a wkq w;aik iys;j

6'

ysl b,a,q lrk ldrKh i|yd fjk;a wdh;khlska rlaIK m%;s,dN ,nd we;s g " fuu wdh;kfhkao m%;s,dN ,nd
.ekSug wfmalaId lrkafka k tu wdh;kfha f. l, uqo, i|yka ,smshla iu. iy;sl lrk ,o ish,qu
bkafjdhsisj,$,am;aj,$l=;dkaisj, Pdhd msgm;a bosrsm;a l, hq;=f'

7'

ksis mrsos imQrAK l, whm; iu. my; i|yka ,sms f,aLK bosrsm;a l, hq;=f'
w' frday,a.;uloS fyda ie;aluloS$yDo ie;alulos$ms<sld frda. wdosh i|yd
frda. ksYaph ldmf;a uq,a msgm; fyda iy;sl l< msgm;la
^ku" we;=,;ajq yd msgjq osk" m%;sldr l, ffjoHjrhdf.a w;aik ks, uq`j ;sh hq;=h'&
fm!oa.,sl frday,l k ;ekam;a ,m;a (Deposit receipts), uqo,a f.jq wjika ,am; (Amount
Receipt) ,ia;rd;aul , (Final Bill ) " wfkl=;a ,m;a yd bkafjdhsisj, uq,a msgm;a ^ku " oskh
fjkia l, uq,q,a msgsgm;a fyda Pdhd msgsgm;a Ndr .kq fkd,ef'&
fm!oa.,sl frday,a j,ska m%;sldr ,nd .ekSfoS iEu jshoulau ia;rd;aulj ,amf;a j. lr olajd ;sh
hq;=h' ffjoHjrhdf.a ho oelafoS fYaI{ ffjoHjrhdg yd wfkl=;a ffjoH jrekag l, ho
fjkfjku oelah hq;=h
fm!oa.,sl frday,l k whmf;a m%Yak wxl ^11& ffjoHjrhdf.a iy;sl w;HjYHf'
yDo ie;aluloS " ie;alu isoq lsrSu i|yd ffjoHjrhd ksl=;a lrk ksfoaY ,smsh'
wd' ore m%iQ;shloS ^wjia:d folloS muKla f.jkq ,ef&
by; ,shlsh,s j,g wu;rj orejdf.a Wmamekak iy;slfha iy;sl l, Pdhd msgm;la fyda Wm;a ia;r
m;%sldf iy;sl l, msgm;la
rcfha frday,l frda. ksYaph ldm; ,ndfkdfokafka k " .rANkS igyka jd;df iy;sl l< msgm;la
^frday,g we;=,;a l, oskh yd msgjq oskh i|yka jsh hq;=hs&
we' weia lKaKd i|yd ^uq,a msgm;a ,nd osh hq;=hs'& - m%Yak wxl 3"4"7"11 msru wjYH fkdf'
fm!oa.,sl ffjoHjrfhl= weia mrSCId lf,a k ffjoHjrhd pek,a l< rsism; yd jfgdarej
^ffjoHjrhdf.a w;aik yd ks, uq`j ;sh hq;=hs'&
rcfha frday,l weia mrSCId lf,a k jfgdarej ^ffjoHjrhdf.a w;aik yd ks, uq`j ;sh hq;=hs'&
lKaKd i|yd uqo,a f.jq ,mf;a f.jd f,i igyka lr wdh;kfha ks, uq`j ;sh hq;=hs' ^wjqreoq
03lg jrla rCIs;hdg muKla f.jkq ,ef&

ksis mrsos imQQK lrk ,o yssl whoqqm; iu. wjYH ,sms f,aaLk tljr kssjerosj bosrsm;a lsrsfuka lk w.%y%ydr
rCIK m%;s,dN m%;smQraK lsrsu hgf;a m%udohlska f;drj m%;s,dN ,nd .; yels nj i,lkaak'