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Dated:
Brlrs I sEcTtoN
(part 'ff) & Column 3 of part 'g to be filled in the Government Servant
4. ResidentialAddress
Surgical operation
(confinement charges)
Medicine suppliea Oy
the Hospital
Bacteriogical Laboratory
or other charges
Cost of medicines
purchased 1. Purchased
from shop not
authorized by
Govt.
ii.lhadmissible
medicines
AAO (Admn)
Sr.AO (Admn) Director (A&C)
//
/
APPENDIX- XItI
MED 97.8
ALso
ATTACHED)
il1 CONSU LTATION WITH SPECIALIST
L2 List of enclosures
I hereby declare that the statement in the application are true to the best of my knowledge and
belief and that the person for whom medical expenses were incurred is wholly dependent upon me.
e)
my treatment from
f) patient is/was given pre-natal or post-natal treatment
iftta,f,"
tests for which an expenditure ofRs"""" """"";""""""
s) That the X-ray, laboratory
was incurred was necessary and were
under taken on my advice at """"""""'
(a name of HosPital or Laboratory)'
h) That I referred the patient to Dr """""' """' for special
of the """""
consultation and that the necessary approval
Medical officer of the state)
iir1lr. of the chief Administrative
it.,
the patient did not require/required hospitalization'
it