1

kmaqly \oXn hIp¸v

tIcf kmaqly kpc£m anj³
(Bizmk IncWw ]²Xn)
am\knI/imcocnI shÃphnfnIÄ aqew AhiXbpÅhsc ]cnNcn¡p¶hÀ¡v
[\klmb¯n\pÅ At]£ t^mdw
1. F. At]£Isâ (]cnNmcIsâ) t]cv :
(_m¦v A¡u−n tcJs¸Sp¯nbXv {]Imcw)
(aebmf¯nepw Cw¥ojv henb A£c¯nepw) :
_n) At]£Isâ (]cnNmcIsâ) ]qÀ® taÂhnemkw :
]n³tImUv klnXw
kn) sF.kn.Un.Fkv t»m¡nsâ t]cv :
Un) ]©mb¯v/ap\nkn¸menän/tImÀ¸tdj³(t]cv) :
C) At]£Isâ (]cnNmcIsâ) P\\ XobXnbpw hbkpw :
F^v) At]£I³ (]cnNmcIsâ) t^m¬ \¼À :
sF) kv{Xotbm/]pcpjt\m :
2. F) ]cnNcn¡s¸Sp¶(AhiX A\p`hn¡p¶ hyàn)
BfpsS t]cv(aebmf¯nepw Cw¥ojv henb :
A£c¯nepw)
_n) ]cnNcn¡s¸Sp¶ hyànbpsS hnemkw :
kn) ]cnNcn¡p¶ BfpsS ]qÀ®amb ta hnemkw :
]n³tImUv klnXw
Un) ]cnNcn¡s¸Sp¶ BfpsS P\\XobXnbpw hbkpw :
C) At]£I\pambpÅ _Ôw :
3. ]cnNcn¡s¸Sp¶ BÄ B{ib/_n.]n.FÂ IpSpw_¯nÂ
s¸« BÄ BtWm/BizmkIncWw ]²Xnb\pkcn¨pÅ
hcpam\ ]cn[nbv¡I¯pÅ IpSpw_mwKamtWm?(BsW¦nÂ
Xt±i kzbw`cW Øm]\ A[nIrXcn \n¶pÅ _n.]n.FÂ
kÀ«n^n¡änsâ tIm¸n lmPcm¡Ww B{ib/_n.]n.FÂ.
tdj³ImÀUnsâ tIm¸n Asæn hntÃPm^okdn \n¶pÅ
hcpam\ kÀ«n^n¡äv lmPcm¡Ww)
_p²namµyw, Hm«nkw,skdn{_Â ]mÄkn, am\knIsshIeyw F¶nhbv¡v
hcpam\ ]cn[n _m[IaÃm¯Xn\m C¯c¡msc ]cnNcn¡p¶hÀ¡v
hcpam\ kÀ«n^n¡äv BhiyanÃ)

4. ]cnNcn¡s¸Sp¶ BÄ am\ZWvU {]ImcapÅ :

AhiXbpÅ BfmtWm?BsW¦n F´mWv AhiX? :
(\nÝnX amXrIbnepÅ saUn¡Â kÀ«n^n¡äv (t]Pv.3)
Kh¬saâv tUmIvSÀ \ÂIp¶Xv)
 2

5. F) At]£I³ (]cnNmcI³) kÀ¡mÀ/AÀ²kÀ¡mÀ/

Øm]\ Poh\¡mct\m kÀ¡mÀ/s]mXptaJe
Øm]\§fn \n¶pw s]³j³/tlmWtädnbw/
dayqWtdj³ ]äp¶ BfmtWm? : AsX/AÃ
_n) BsW¦n {]Xnamk hcpam\w :
6. At]£Isâ(]cnNmcI³) t£as]³j\pIÄ e`n¡p¶
BfmtWm? BsW¦n GXv s]³j³ F¶pw {]Xnamk
s]³j³ F{Xsb¶pw hyàam¡pI.
7. At]£Isâ t]cn _m¦n Bcw`n¨ A¡u−nsâ hniZmwiw
A¡u−v \¼À
_m¦nsâ t]cv :
{_m©nsâ t]cv
sF.F^v.Fkv. tImUv :
8. At]£Isâ(]cnNmcI³) B[mÀ ImÀUv \¼À
(Csæn B[mÀ cPnkvt{Sj³ \¼À) :

kXy{]kvXmh\
At]£bn ]dbp¶ ]cnNcWw BhiyapÅ {io/{ioaXn/Ipamcn............................
………………… F¶bmÄ Fsâ ]cnNcW¯nemsW¶pw SnbmÄ am\knI/imcocnI shÃphnfnaqew
AhiXbpÅbmsW¶pw At]£bn ]dbp¶ hnhc§Ä ]qÀ®ambpw icnbmsW¶pw {]kvXmh\ sNbvXpsImÅp¶p.

At]£Isâ t]cpw H¸pw:

Øew: ]cnNcn¡s¸Sp¶ BfpsS

XobXn: t]cpw H¸pw
 3

Photo of bedridden patient

attested by Doctor
Aswasakiranam

MEDICAL CERTIFICATE
This is to certify that Sri/Smt/Kumari/Master……………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
(Name&Address)aged……… is completely bedridden due to
……………………………………………………………………………………………(Name of disease), hence needs a fulltime
caregiver/ is 100% blind hence needs a full time caregiver/ is moderately/ severely mentally challenged,
hence needs a full time caregiver/ suffering from Cerebral Palsy /Autism, hence needs a full time caregiver/
suffering from severe mental illness (Schizophrenia/ Severe Mood disorder) hence needs a full time caregiver.
Strike out which is not applicable.
Identification marks of the Patient

Signature:
Name & Designation of the Doctor……………………………………..
Registration No:
Name of the Hospital

Office Seal
Place:
Date:
{]tXyI {i²bv¡v
Iym³kÀ, ]£mLmXw, aäv \mUotcmK§Ä F¶nh aqew Hcp apgph³ kab ]cnNmcIsâ tkh\w BhiyapÅhn[w
InS¸nemb tcmKnIÄ, {]mb[nIyw aqew InS¸nembhÀ, 100 iXam\w AÔX _m[n¨hÀ, Xo{ham\knI tcmKapÅhÀ
_p²namµyw,Hm«nkw,skdn{_ ]mÄkn apXemb _p²n]camb shÃphnfnIÄ t\cnSp¶hÀ F¶nhsc ]cnNcn¡p¶hÀ¡mWv
BizmkIncWw ]²XnbpsS B\pIqeyw e`yam¡pI. saUn¡Â kÀ«n^n¡änsâ ASnØm\¯nemWv [\klmbw
A\phZn¡p¶Xv. BbXn\m IrXyX Dd¸phcpt¯−XmWv. saUn¡Â kÀ«n^n¡äv hyàhpw IrXyhpw Bbncnt¡−XmWv.
hnhc§Ä¡v 0471-2341200 F¶ \¼dn _Ôs¸Smhp¶XmWv.
 4

(Hm^okv D]tbmK¯n\v am{Xw)

(sF.kn.Un.Fkv. kq¸ÀsshkdpsS At\zjW dnt¸mÀ«v)

{io/{ioaXn/Ipamcn…………………...........kaÀ¸n¨ At]£bpw A\p_Ô tcJIfpw ]cntim[n¡pIbpw

At]£bn³ta Bhiyamb At\zjWw \S¯pIbp−mbn AhiXb\p`hn¡p¶
{io./{ioaXn/Ipamcn……………………..SnbmfpsS ………………(_Ôw) Bb
{io./{ioaXn/Ipamcn………………………….bpsS ]qÀ® kwc£WbnemWv Ignªphcp¶sX¶v F\n¡v
At\zjW¯n t_m²ys¸«n«p−v. SnbmÄ BizmkIncWw ]²XnbpsS am\ZWvU§Ä A\pkcn¨v B\qIqey¯n\v
AÀlbmWv. SnbmÄ¡v [\klmbw A\phZn¡p¶Xn\v ip]mÀi sNbvXpsImÅp¶p.
Øew: H¸v
XobXn: t]cv
……………………….......…sF.kn.Un.Fkv.t{]mPIvSv
NB:ICDS kq¸ÀsshkÀ saUn¡Â kÀ«n^n¡äpw aäv tcJIfpw ]cntim[n¡p¶tXmsSm¸w At]£Is\¸än t\cn«v At\zjn¨Xn\v tijw
am{Xw ip]mÀi sN¿pI.

inip hnIk\ ]²Xn Hm^okdpsS ip]mÀi

At]£bpw At\zjW dnt¸mÀ«pw ]cntim[n¨Xn …………………………………………..bmÄ
BizmkIncWw ]²Xn B\pIqey¯n\v AÀl\mWv/AÀlbmWv/AÀlXbnÃ. SnbmÄ¡v [\klmbw A\phZn¡p¶Xn\v
ip]mÀi sNbvXp sImÅp¶p.

Øew: H¸v
XobXn:
(Hm^okv ap{Z) t]cv
(Designation Seal)
…………………………. …………….sF.kn.Un.Fkv.t{]mPIvSv
……………….......………PnÃ
Hm^okv t^m¬ \¼À

tIcf kmaqly kpc£m anj³ doPnbWÂ UbdIvSdpsS Xocpam\w

io./{ioaXn/Ipamcn……………………………F¶bmÄ¡v BizmkIncWw ]²Xn
{]Imcw………………………………apXÂ……………………………………………cq]m\nc¡n {]Xnamk
[\klmbw A\phZn¨ncn¡p¶p.

doPnbWÂ UbdIvSÀ
 5

amÀ¤ \nÀt±i§Ä
1. At]£ ]qÀ®ambpw ]qcn¸n¨ncn¡Ww. A]qÀ®mb At]£IÄ ]cnKWn¡p¶XÃ.
2. kÀ¡mÀ, htbman{Xw,F³.BÀ.F¨v.Fw.tUmIvSÀamÀ km£ys¸Sp¯nb saUn¡Â kÀ«n^n¡äv DÅS¡w
sNbvXncn¡Ww. saUn¡Â kÀ«n^n¡än Hm^okv ko ]Xn¸n¨ncn¡Ww, t^mt«mbn saUn¡Â Hm^okÀ AäÌv
sNbvXncn¡Ww.
3. hcpam\w sXfnbn¡m³ _n.]n.FÂ tdj³ ImÀUnsâ tIm¸ntbm, ]©mb¯v/ap\nkn¸menän/tImÀt¸tdj³
sk{I«dnbn \n¶pÅ _n.]n.F kÀ«n^n¡äv Asæn hntÃPv Hm^okdn \n¶pÅ hcpam\ kÀ«n^n¡äv
lmPcm¡nbncn¡Ww hcpam\ kÀ«n^n¡än InS¸v tcmKnbpsS hcpam\amWv ]cnKWn¡pI.
4. At]£Isâ B[mÀ ImÀUnsâ tIm¸n Asæn B[mÀ cPnkvt{Sj³ Én¸nsâ tIm¸n DÅS¡w sNbvXncn¡Ww.
5. At]£IÄ _Ôs¸« iniphnIk\ ]²Xn Hm^okn kaÀ¸nt¡−Xpw ssI¸äv ckoXv hm§n kq£nt¡−XpamWv.
6. FÃm hÀjhpw Pq¬amkw Hmtcm sF.kn.Un.Fkv. t»m¡ntebpw KpWt`màm¡fpsS enÌv {]ImcapÅ sse^v
kÀ«n^n¡äv iniphnIk\ ]²Xn B^nkÀamÀ sI.Fkv.Fkv.Fw. FIvknIyq«ohv UbdIvSÀ¡v \ÂtI−XmWv.
7. FÃmamks¯ AwK³hmSnhÀ¡mÀamcpsS t{]mPIvSv aoänwKn BizmkIncWw ]²Xn AhtemI\w DÄs¸Spt¯−Xpw
KpWt`màm¡fn acWs¸«hcpsS enÌv AwK³hmSn hÀ¡mcn \n¶pw \nÝnX amXrIbn tiJcnNNv 15þmw XobXn¡v
ap¼v iniphnIk\ ]²Xn Hm^okÀ tIcf kmaqly kpc£m anj³ FIvknIyq«ohv UbdIvSÀ¡v Abvt¡−XmWv.
8. ]cnNmctIm\, ]cnNcn¡s¸Sp¶ hyàntbm acWs¸«m hnhcw 15 Znhk¯n\pÅn iniphnIk\ ]²Xn Hm^oksd
Adnbnt¡−XmWv.
9. amÀ¤ \nÀt±i§fpw ssI¸äv ckoXpw At]£I³ kq£nt¡−XmWv.
10. ]gb amXrIbnepÅ At]£ t^md§fpw At]£IÄ ]cnKWn¡p¶nÃ.
…………………………………………………………………………………………………………….
ssI¸äv ckoXv
BizmkIncWw ]²Xn {]ImcapÅ [\klmb¯n\v th−n {io/{ioaXn…………………………………………XobXn
kaÀ¸n¨ At]£ Cu Imcymeb¯n ssI¸änbncn¡p¶p.

iniphnIk\ ]²Xn Hm^okdpsS t]cpw

H¸pw XobXnbpw

BizmkIncWw ]²Xn
acW hnhcw dnt¸mÀ«v sN¿p¶ t^mdw

BizmkIncWw cPnkvt{Sj³ \¼À

Bizmk IncWw ]²Xn KpWt`màmhmb {io/{ioaXn (t]cpw

A{UÊpw)……………………………………………………………………..…….F¶
hyàn/]cnNcn¡s¸«Xmbn Adnbn¡p¶p. BbXn\m {io/{ioaXn……………………………………F¶
hyànbv¡pÅ [\klmbw XpSct−Xnà F¶v Adnbn¡p¶p.

inip hnIk\ ]²Xn Hm^okdpsS

t]cpw H¸pw XobXnbpw