.ef. .No.(Dir Sectt.

iz&r ink$kZ r$kk izdz! vu(la)kku la*$kku% +kksiky

:oS;kfud 3oa vkS<ksf8d vu!la$kku ifj"kn=>

No. of )ages:

A&'A CE& MATE(IA)S A & *(+CESSES dsUnzh; ljdkjh lsodksa ,oa muds ifjokj ls lEc) fpfdRlk O;; dh izfriwfrZ ds fy, nkok djus ds fy, vkosnu izi= Form of Application for Claiming refund of Medical Expenses Incurred in connection with Central Government Servants & Their Families Vhi ! "! # izR;sd !jh" ds fy, i#$kd%i#$kd izi= mi;ks& !sa yk;k "k;s'
Separate form should $e used for each patient! 1) i. ljdkjh lsod dk uke@Name of the Govt. Servant: (Li"V v{kjksa esa@in block letter) ii.

inuke@Designation

: :

iii. fookfgr iv.

;k vfookfgr@Whether married or unmarried

;fn fookfgr gSa rks iRuh@ifr fdl LFkku ij fu;ksftr gSa %

If married the !lace "here Wife#$usband is em!lo%ed

&) ()

fdl dk;kZy; esa fu;ksftr gSa@'ffice in "hich em!lo%ed : ewy fu;ekoyh dh ifj kk"kk vu!lkj ljdkjh lsod dk ewy % osru vkSj v"; ifjyf#$k;k%& tks fd i'Fkd n(kkZ;h tk;sa
)a% of the Govt. Servant as defined in the fundamental rules and an% other emoluments "hich should be sho"n se!aratel%

*) ,) -) i.

okLrfod fuokl LFkku@+ctual residential +ddress : dRrZ); LFkku dk uke@ )lace of dut% ejht dk uke@Name of !atient
: ii. ljdkjh lsod ls ejht dk la*a$k .elationshi! of the !atient to the Government servant iii. ejht dh vk;!@+ge of the !atient : (fl+Z *,-ksa ds i.dj/k esa@in case of /hildren onl%) :

0) 1)

LFkku tgk% ejht *hekj g!vk@)lace at "hich the !atient fell ill : nkok jkf(k dk fooj/k@ Details of the amount claimed
i. ijke(kZ a.) ijke(kZnkrk :

0k!1d ftleas n(kkZ;k gks@2ees for consultation indicating :

f-fdRlk vf$kdkjh dk uke& 0kS{kf/kd ;ks2;rk 3oa % inuke vkSj fdl vLirky ;k nok4kkus ls l5*6 gSa7
3he name 4ualification 5 Designation of the 6edical 'fficer /onsulted and the $os!ital or Dis!ensar% to "hich attached.

b.) ijke(kksZa dh la4;k 3oa fnukad vkSj 89Z +hl # 3he No. and dates of consultations and the fee !aid for each consultation.

i.R;sd ijke(kZ esa nh %

c.) 9ats?(ku

dh la4;k 3oa fnukad vkSj i.R;sd 9ats?(ku ds fy3 % nh 89Z +hl @3he No. and dates of in7ections

and the !aid for each in7ection.

+!r &;11 2orm No >I(11) .evision 1 )age 18*

d.) ijke(kZ@

9ats?(ku vLirky esa@ f-fdRlk vf$kdkjh ds ijke(kZ d{k esa ejht ds fuokl ij fn;k 8;k

Whether consultation and#or In7ections : "ere had at the hos!ital# at the consultation room of the medical 'fficer of at the residence of the !atient. e.)

funku ds nkSjku djok;s 83 iSFkkyk@ftdy& *S?Vhfj;ksyk@ftdy % jsfA;ksyk@ftdy ;k v"; ln'(k ijh{k/kksa ds fy3 fn;k 8;k 0k!1d ftlesa n(kkZ;k gks @ /harges for !athological
bacteriological radiological or other similar tests under8 taken during diagnosis indicating.

f.) 9)

*ktkj ls B; dh 89Z nokvksa dh dher

/ost of medicines !urchased from the market.

% %

nokvksa dh lw-h& dS(k eseks vkSj vfuok;Zrk i.ek/k iC lay2u fd;k tk;s@:ist of medicines cash memos and
the essentialit% certificate should be attached.

1;) 11)

nkokd'r d!y jkf(k@ 3otal amount claimed lay2udksa dh lw-h@ :ist of enclosures.

: :

,kks-k.kki= ljdkjh lsod /kjk 0*rk1kfjr fd;k "k;s

&EC)A(ATI+ T+ "E SIG E& ", T-E G+'T! SE('A T

eSa 3rn=Dkjk Ekks"k/kk djrk gw% fd 9l vkosnu esa fn;s 8;s dFku esjs loksZRre ;ku vkSj fo(okl ds vk$kkj ij lR; gSa vkSj );f?r ftlds fy3 f-fdRlk );; fy;k tk jgk gS& og iw/kZr;k e!F ij fu kZj gS7 ;g i.ekf/kr fd;k tkrk gS fd kksiky esa nokvksa la*af$kr dks9Z ljdkjh@ lgdkjh Gf-r ew1; dh n!dku ugha gS7
I hereb% declare that the statements in this a!!lication are true to the best of m% kno"ledge and believe that the !erson for "hom medical e<!enses "ere incurred is "holl% de!endent u!on me. 3his is to certif% that there is no Govt.#/o8o!erative fare !rice sho! at =ho!al dealing in medicine.

fnuakd@Date :
of Govt. Servant

ljdkjh lsod ds gLrk{kj@Signature {ksCh; vu!la$kku i.;ks8(kkyk& kksiky@.egional

.esearch :aborator% =ho!al

HIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIds ikl
)assed for !a%ment of .s.8888888888888888888888888888888888888888888

k!8rku ds fy3

:Hi;sIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIII>
(.s.888888888888888888888888888888888888888888888888888888888888888888888)

vkgj/k 3oa laforj/k vf$kdkjh

D. D. '.
+!r &;11 2orm No >I(11) .evision 1 )age &8*

vfuok;Zrk iz!k.k i=
ESSE TIA)IT, CE(TIFICATE IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIeas fu;ksftr Jh@ l!JhIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIi!C@ i!Ch@ iRuh@ Jh@ l!JhIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIdks i.ek/kiC i.nku fd;k tkrk gS7
Certificate granted to Mr./Miss. Son/Daughter/Wife/Mother of Mr./Mrs./Miss. Employed in. iz!k.k i= 2d2 CERTIFICATE A

:Gu ejhtksa ds i.dj/k eas

kjk tk3 tks Gi-kj ds fy3 vLirky esa ugha Fks>

krhZ

(To be completed in the case of patients ho are not admitted to hospital for treatment! "# Ak@I@Dr...... .. (a! ;g fd eSaus

fnukadIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII dksIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIijke(kZ +hl HIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIvius ijke(kZ d{k@ ejht ds fuokl ij i.kKr dh 7

that $ charged and recei%ed &s for.consultation on.. at my consulting room / at the residence of the patient. (b!

;g fd eSaus fnukadIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIdks IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII9aVLkohul@ 9aVLkeL?;wyj@ l*?;wVsfu;l 9ats?(ku nsus ds fy3 +hl HIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIesjs ijke(kZ d{k@ ejht ds fuokl ij i.kKr fd;s7
that $ charged and recei%ed &s...for administering .. intra%enous/intramuscular/subcutaneous $n'ections on at my consulting room/at the residence of the patient.

;g fd y8k;s 8;s 9ats?(ku Vhdkdj/k ;k i.ks+hysf?Vd i.;kstu@ ds fy3 Fks@ ugha Fks7
that the in'ections administered ere/ ere not for immuni(ing or prophylactic purposes.

M*6 ;g fd ejht esjs ijke(kZ d{k esa Gi-kj ds nkSjku Fkk vkSj ;g fd 9l la*a$k esa fu5ufyf4kr nok9Z;k% esjs Dkjk fofgr dh 89Za& tks fd ejht dks Nhd djus ds fy3 vfuok;Z Fkh7
that the patient has been under treatment at my consulting room and that the undermentioned medicines prescribed by me in this connection ere essential for the reco%ery of the patient.

;g nok9Z;k% ljdkjhIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIvLirky esa i.k;osV ejht dks vkiwfrZ ds fy3 LVk@d essa ugha Fkh vkSj 9uesa Lok5;k$khu laikd 0kkfey ugha gSa ftuds fy3 leku oS$kkfud ew1; ds lLrs inkFkZ Giy#$k gS rFkk ;s i.e!4kr% 4kk<& i.lk$ku 3oa dhVk/k!uk(kd lkef8.;k% kh ugha gSa7
The medicines are not stoc)ed in the *o%ernment ..................................................................................................................................+ospital for supply to pri%ate patients and do not include proprietary preparations for hich cheaper subtances of e,ual therapeutic %alue are a%ailable not preparations hich are primarily foods -toilets or disinfectants . ew1;@.rice BI ew1;@.rice

BI

S./o.

nok9;ksa dk uke
/ame of Medicines

HI @&s.

iSls@
..

S./o.

nok9;ksa dk uke
/ame of Medicines

HI @&s
.

iSls @..

;g fd ejhtIIIIIIIIIIIIIIIIIIIIIIIIIIIIIls ihfAOr gS@ Fkk vkSj esjs Gi-kj eas fnukadIIIIIIIIIIIIIIIIIIIIIIls IIIIIIIIIIIIIIIIIIIIIIrd Fkk7
(e! that the patient is / as suffering from is/ as under my treatment from to
+!r &;11 2orm No >I(11) .evision 1 )age (8*

(f! (g!

;g fd ejht dks i.h usVy Gi-kj ugha fn;k 8;k7

that the patient as not gi%en pre natal treatment.

;g fd 3?lPjs M i.;ks8(kkyk ijh{k/k vkfn ds fy3 HIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIdk );; vko(;d Fkk& tks fd esjh lykg ij IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIesa djok3 837

that the 01ray- 2aboratory test etc3 for hich an e4penditure of &s as incurred as necessary and ere underta)en on my ad%ice at . (vLirky@ (h!

i.;ks8(kkyk dk uke@name of the +ospital or 2aboratory!

;g fd eSusa ejht dks Ak@IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIdks fof(k"V ijke(kZ ds fy3 jS+j fd;k vkSj ;g fdIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII:jkQ; ds e!4; i.(kklfud f-fdRlk vf$kdkjh dk uke> vko(;d vu!eksnu tks fd fu;ek$khu vko(;d ;k& i.kKr dj fy;k Fkk7
that $ referred the patient to Dr. for specialist consultation and that the necessary appro%al of the (/ame of the chief administrati%e Medical 5fficer of the state! as re,uired under the rule as obtained.

(i!

;g fd ejht dks vLirky esa

krhZ djus dh vko(;drk Fkh@ ugha Fkh > ij i.fo"V feJ/k@ eyge@ -w/kZ vkSj ejht dks 9ls *ktkj ls B; djus dh

that the patient did not re,uire/re,uired hospitali(ation. ('!

;g fd i.ek/k iC ds v$khu BI : vLirky esa ugha fn;k tk ldk lykg nh 89Z7

that the mi4ture /ointment /po der entered at serial ( ! under certificate(d! could not be dispensed at the hospital and the patient as ad%ised to buy it from the mar)et.

()! ;g

fd 9ats?(kuksa dh la4;kIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII@Gi-kj vof$k@ fofgr vof$k@ la4;k ls vf$kd Fkh vkSj ejht dks iw/kZ Nhd gksus ds fy3 vko(;d Fkh7

that the period treatment //oof in'ection in e4cess of the prescribed one as/ ere essential for the complete reco%ery of the patient .

fnukad@Date 6 f-fdRlk vf$kdkjh ds gLrk{kj& inuke vkSj iathdj/k BI vkSj fdl vLirky@ fALisaljh ls l5*6 gS
Signature - Designation and &egd. /o. of the Medical 5fficer 7 the +ospital /Dispensary to hich attached

+!r &;11 2orm No >I(11) .evision 1 )age *8*