FORMS AND CERTIFICATES
APPENDIX II FORM
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE AND TREATMENT OF GOVERNMENT SERVANT AND THEIR FAMILIES
1. Name and Designation & Section :
(in Block Letter)
2. Office of the employee :
3. Pay of the Govt. Servant as defined in FRs and other employments which should be shown :
separately
4. Place of duty :
5. Full Residential address with door No And name of the Mohalla :
6. Name of the patient, his / her relationship to the Govt. Servant. In case of children state age also :
7. Place at which the patient fell ill :
8. Nature of illness and its duration :
9. Details of amount claimed, cost of Medicines purchased from the Market / List of medicines / cash memos, and the Essentiality certificate should be attached Each in duplicated signed by treatment doctors :
10. Total amount claimed : Rs.
11. List of Enclosures
i. Check List :
ii. Essential Certificate :
iii. Emergency Certificate :
iv. Discharge summary :
v. Consolidation Bills :
vi. Medical Cash bill :
vii. Operation Notes :
ix. Non-Drawal Certificate :
viii. Dependence certificate :
x Referral proceedings :
xi Reports :
xii Pension :
xiii Others :
DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT / PENSIONER
I here by declared that the statement in the application is true to the best of my knowledge and belief and that the person from whom medical expenses were incurred is a member of my family as defined under the Government servant Medical attendance rules 1972 and wholly dependent upon me.
Signature of Forwarding authority Signature of Govt. Servant / Pensioner and office to which attested