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OFFICE OF THE PRINCIPAT DIRESTOR OF AUDIT {CENTRALI. BANGATORE

Dated:

Brlrs I sEcTtoN

Subject: Reimbursement of expenses incurred connection with


Medical attendance and/or treatment.

(part 'ff) & Column 3 of part 'g to be filled in the Government Servant

and submitted along with application.


PART'A,
1. Name of the Government servant (in Block
Letters) & Designation
2. Whether married and if so whether
wife/husband is employed whether joint
declaration furnished.
3. Section in which working

4. ResidentialAddress

5. Name of the patient & his/her relationship to


the Government servant.
5. Name of the HOSPITAL/DISPENSARY where the
treatment obtained.
7. Period of treatment
8. In case of medical attendance the name &
Designation of the A.M.A consulted and the
Hospital to which he is attached.
9. Total amount claimed
10. D]SEASE
11. Details of medicines Purchased
sl. Cash Name of Medicines purchased (ln Quantity Cost Remarks
No Memo No Chemist Block letters)
and date

SIGNATURE OF THE GOVERNMENT SERVANT


PART'B'

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

1. Checked with the list of in admissible


medicines.
1' fh,"
dtitt tt" t' d by pr.r.rioeJ c".titicates and

PART'C' SANCTION ORDER:

The refund of Rs. ..........


indicated above is sanctioned.

AAO (Admn)
Sr.AO (Admn) Director (A&C)
//
/

APPENDIX- XItI

MED 97.8

FORM OF APPLICATION FOR CLAIMING REFUND


OF MEDICAL EXPENSES INCURRED IN
CONNECTION WITH MED]CAL ATTENDANCE AND/ OR TREATMENT
OF CENTRAL GOVERNMENT
SERVANTS AND THEIR FAMI L]ES

FOR MEDICAI ATTENDANCE BY AUTHORISED MEDICAT


ATTENDANT.

Name and designation of Govt


Servant (ln Block Letters)

i. Whether married or unmarried


ii. lf married, the place where wife/husband
is employed

Office in which employed

Pay of the Government servant as OeRneO in


the Fundamentalwhich should be shown
separately

Name of the patient and his/her relationship


to the Government servant.
NB- IN THE CASE OF CHILDREN STATE AGE

ALso

Place at which the patient fell

Details of the amount claimed

Fees for consultation indicating


a) The name & designation of the Medical
Officer consulted and the hospital or
dispensary to which attached
b) The number and dates of consultation
and the fee paid for each consultation
c) The number and dates of injection and
the fee paid for each injection.
d) Whether consultations and or injections
were had at the hospital at the consulting
room at the residence ofthe patient
Charges for pathological, bacterinlogical
or other similar tests
undertaken indicating
a) The name of the hospital or laboratory
where undertaken and
b) Whether the tests undertaken on the
advice of the authorized medicalattendant.
lf so, a certificate to the effect should be
attached
c) Cost of the medicines purchased from the
market (CASH MEMO AND THE
ESSENTIALITY CERTI FICATES SHOU LD BE

ATTACHED)
il1 CONSU LTATION WITH SPECIALIST

Fees paid to a Specialist or a Medical Officer


other than the authorized Medical
attendant, indicating
a)The name and designation of the
Specialist or medical Officer consulted and
the Hospital to which attached
b) Number and date of consultations and
the Fees charges for each consultation
c) Whether consultation was had at the
Hospital, at the Hospital, at the consulting
room of the Specialist or Medical Officer, or
at the residence of the patient, and
d) Whether the Specialist or Medical Officer
was consulted on the advice of the
authorized Medical attendant and the prior
approval of the Chief Administrative officer
of the state was obtained. lf so, a certificate
to the effect should be attached
9 Totalamount claimed

10 Less advance taken on

7T Net amount claimed

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.

Signature of the Government Seruant


and office to which attached
Certificate granted to Mrs/Mr/Miss """"""""
Wife/son/daughter of Mr ..."""'
Employed in the .......'..
(To be completed in the case of patient who are
not admitted to any hospital)

"' hereby certify'


I Dr.."'...'...
a) That I charged and received
consultation and consulting rooms/at the
ns. ___for
residence of the Patients. intra
for administering
That I charges and received Rs'
at mY consulting room the
at
muscular sub-coetaneous/intra injection on
residence of the Patient.
c) That the injection administered were not for im
at
d) That the patient has been under treatment
and that the under mentioned medi
the recovery/ prevention of serious
for the supply to private
are not stocked in the (name of the
eaper substances of equal
patients and do not include laboratory preparati for
preparations which are primarily foods toilets
therapeutic value are available not
disinfectants.
Name of the medicine
Name of the medicine

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

Signature and Designation of the


fUedical officer and the HosPital
DispensarY to which aftached

compulsorY and must be filled

in by the Medical Officer in all cases'

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