PERFORMA FOR SANCTIONING OF EXPENDITURE INCURRED ON MEDICAL

TREATMENT FOR INDOOR / OUTDOOR PATIENT / FOLLOWUP TREARMENT OF

EMPLOYEES / DEPARTMENT OF EMPLOYEES WORKING IN THE DEPARTMENT OF
SCHOOL EDUCATION
Sr.
Particulars Discription
No.
Name of Claimant / Employee with I. D.
1 Number

2
Designation

3
Date of Regulisation into service
Basic Pay ( Pay in the particular Pay Band
4 + Grade Pay )

5
Present Place of Posting
6 Whether indoor patient or outdoor patient.

7
Period of Treatment.
whether claim is within prescribed time limit
8 ( within one year of the treatment )
9 Name of Hospital

whether the Hospital is

a) Government Hospital
10

b) Approved Hospital as on Date

c) Unapproved Hospital
In case the treatment is taken from an
unapproved hospital attach the orignal
11 certificate of emergency issued by the cival
surgeon. ( Mension No. & Date of issue
and the issuing authority. )
Where the claim relates to the treatment of
the dependent, give the following details:

a) Relationship with the claiment.

12
b) Monthly income of the
Dependent.
c) Affidavit about the dependency
upon the claimant.
Where the claim relates to the treatment as
13 outdoor patient, attach the following
documents:

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 Sr.
Particulars Discription
No.
a) Certificate issued / renewed by
the Competent Board with regard to
13 A the chronic ailment. (Mension No.
& Date of issue and Name of the
Competent Authority)
b) Authorisation by the Competent
Authority with regards to the change
13 B of the option. (Mension No. & Date
of issue and Name of the
Competent Authority)
Admissible amount of reimbursement as
14 per calculation sheet. ( Annexure 'A' )

15
Amount of medical advance given, If any.

16
Balance Amount

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 Annexure 'A'
CALCULATION OF ADMISSIBLE/NON ADMISSIBLE AMOUNT OF MEDICAL REIMBRURSEMENT O
Sr. Description Cash Memo Gross Admissible amount
No. No. with date Amount at Govt./PGI/AIMS
Rates. (Tick any as
applicable giving Sr.
No. as per Rate List)

Signature of Clerk

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 Annexure 'A'
ICAL REIMBRURSEMENT OF SHRI _______________________ DESIGNATION _____________________
Non Balance (Co.4- 75% of Col No. Total Remarks
Admissbile (5-) 7 Admissible
amount amount (Col.
No. 5+8)

Signature & Seal of Princpal /Head Master

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