NON AVAILABILITY CERTIFICATE

Name of Government Servant: ______________________________________________

Designation:_____________________ Name of Patient: __________________________

Age:_______________ Disease: ____________________________________________

Relation with Government servant:

___________________________________________

Amount claimed Rs: _______________________________________________________

Cash memo number with amount for non reimbursable items:

_____________________

Cash M.N: _______________________________________________________________

Amount recommended by Hospital Pharmacist Rs:

______________________________

(In word): _______________________________________________________________

INITIAL OF HOSPITAL
PHARMACIST

(i) All cash memos have been thoroughly checked against

prescription: _____________

(ii) Cost given in vouchers are correct:

______________

(iii) Total amount has been calculated:

______________

(iv) Neither these medicines/rests/items not their

______________
effective substitute were available in the stock
of this Hospital at the time of treatment:

(v) All items recommended for re-imbursement

______________
As their use were essential for treatment of the
Patient:

(vi) No medicines was proscribed vas tonic or food:

______________

(vii) No non-reimbursable items are being recommended

______________
Justification (other than given at (v) about if any non-reimbursement items
has been recommended:

Alongwith vouchers an amount: _____________________________________________

_______________________________________________________________________

HOSPITAL PHARMACIST AUTHORIZED MEDICAL

ATTENDANT
EMBOSSING SEAL MEDICAL SUPERINTENDENT

S J Haider / * * * * *