ffjoH yd frday,a .dia;= ysulus b,a,qus m;%h ^w.

%ydr&

(SMS)

( )

^Pdhd msgm; wuqKkak&

Tnf.a yslu wod, jkafka

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

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

1'1

ms<sld

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

fjk;a frda.

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

uq,l=re iu. ku ^bx.%Sisfhka&()--------------------------------------------------------------1'2

mqoa.,sl ,smskh(^isxyf,ka&()'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

1'2

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

1'3

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

1'4

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

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

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

cd;sl wxlh()

3'2

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

3'3

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

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

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' nexl= .sKq ms,sn iaa;rh ()

5'1

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

5'2

.sKq wxlh

5'3

nexl=f ku(- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' nexl= YdLdj(- ''''''''''''''''''''''''''''''''''''''''''''''''''

" fld<U 10"

wxl ( 0114)873901)5

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

*elaaia () 0114 ) 702667

6' fuu whq m;g wod, ho ckdm;s wruqof,ka fyda fjk;a wdh;khlska b,a,qlr fyda f. lr ;sf k tu
ia;r"
6'1

wdh;kfha ku iy ,smskh(- '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

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

6'2

f.jQ uqo,(- '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

6'3

wxlh $fhduq wxlh(- ''''''''''''''''''''''''''''''''''''''''''''''

7' whqlref.a m%ldYh

by; ioyka f;dr;=re i;H yd ksjeros nj;a" uu fyda uf.a l,;%hd fuu mEu by; 06 fcaohg hg;aj fjk;a
wdh;khlska" fjk;a l%uhla u.ska fyda ta ioyd b,a,Sula bosrsm;a lr fyda fkdue;s nj uu fuhska iy;sl fj'
oskh()

''''''''''''''''''''''''''''''''''' ''''''''''''''''''''''''''''''''''''''''''''''''''
whqlref.a w;aik

8' wdh;k m%Odkshdf.a iy;slh()

uf.a wxlh() '''''''''''''''''''''''''''''''''''''''''''''''
by; ia;r ioyka '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''uy;d$ uy;ahf.a rCIK yslu wjYH lghq;= ioyd
ksfoaYlr iu. bosrsm;a lr' by; ioyka f;dr;=re i;H yd ksjeros nj;a" Tyqf.a$wehf.a fm!oa.,sl ,smsf.dkqj
wkqj iy;sl lr' rlaIs;hd m%;sldr ,enQ frdayf,ka neyerjQ udihg fmr udih jQ '''''''''''''''''''''''''''''''''''''''''udifha odhl uqo,
whlr ''''''''''''''''''''''''''''''''''''''''''''''''''''''''nexl= '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''YdLd wxl '''''''''''''''''''''''''''''''''''''''''''''''''' orK fplam;lska cd;sl rlaIK Ndr
wruqof,a uyck nexl=fjs /csk YdLdfjs 033-2-001-2-2467951 orK .sKqug nerl< remsh,a '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''l uqo,g
we;=,;a lr we;'
w;aik() '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
ku() ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
oskh() ''''''''''''''''''''''''''''''''''''''''

;k;=r() '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
^ks, uqo%d%dj ;eu w;HjYHhs&s&

9' frda.shdf.a fYaIaI{ ffjoHjrhd $Y,H ffjoHjrhd isska l< hq;qh'^fm!oa.,sl frday,l fkajdisslj
m%;sldr ,nd we;akq muKla fuu fldgi l< hq;qh'&
Should be filled by the specialist / Surgeon of the Patient.
9.1 Name of the Patient:-
9.2 Diagnosis of Disease:-

9.3 Date of Admission:-

Date of Discharge:-
I hereby certify that I am specialist / Surgeon of the above named patient and approve submission with
regard to this claim.
.
Date:..
Signature of Specialist / Surgeon

whm; imQrAK imQrQrAKAK lsrsrSuSu i|yd Wmfoia

^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'