10. Total amount claimed. Rs. 11. List of enclosures. Hospital Bill cash Memo. 12. Size of family i.e.living children as on and thereafter
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1 Form of application for claiming refund of Medical Expenses incurred in connection with Medical Attendance and / or treatment of Central/State Government servants and their Family. N.B. :- Separate form should be used for each patient. 1. Name and Designation of the G.S. : 2. Office in which employed. : 3. Pay of the Government servant as defined in the F.R.and any other emoluments which should be shown separately. 4. Place of duty. : 5. Officetual residential address. : 6. Name of the patient and his/her : 7.Place at which the patient fell ill. : 8. Nature of illness and duration : 9. Details of the amount claimed : Medical Attendance (1) Fees for consultation indicating- (a) the name and designation : of the Medical Officer consulted and the Hospital or Dispensary to which attached. (b) the number and dates : of consultation, and fee paid for each consultation (c) whether consultation : were/had at the hospital at the hospital at the consulting room of the Medical Officer or at the residence of the patient. (11) Charges for pathological, : bacteriological, radiological or other similar tests undertaken during diagnosis indicating. (a) the name of the hospital or : laboratory where the test were undertaken PTO.
2 (b) Whether the test was : undertaken on the advice of the authorised medical attendant. If so, a certificate to that effect should be attached. (111) Cost of Medicines purchased Rs. from the market (List of medicines, each memo should be attached). CONSULTATION WITH SPECIALIST Fees paid to a specialist or a Medical Officer other than authorised Medical Officer than the authorised Medical Attendant, indicating :- (a) the name and designation of the Specialist or consulted and the hospital to which attached. (b) Number and date of consultations and the fees charged for each consultation. (c) whether consultations : was/had at the Hospital, at the consulting room of the specialist or Medica; Officer or at the residence of the patient. (d) Whether the Specialist : or Medical Officer was consulting on the advice of the prior approval of the Chief Administrative Medical Officer of the Province. If so, a certificate to that effect should be attached. 10. Total amount claimed. Rs. 11. List of enclosures. Hospital Bill cash Memo 12. Size of family i.e.living children as on and thereafter 2 (Two) DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT I hereby declare that the statement in this application are true to the best of my knowledge and behalf of that the person for whom medical expenses were incurred is wholly dependent on me. Office to which attached. Signature of the Government Servant
3 ----- FORM - "D" CERTIFICATE OF EXPENDITURE INCURRED (IN DETAILS) FOR THE GOVERNMENT SERVANT TREATED FOR EMERGENCY IN PRIVATE HOSPITAL. ( To be filled in by treating doctor and to be attached to Annexure "c") Name of Patient Date of admission Date of Discharge Hospital Registration No. Charges :- A) (1) consultations (2) Indoor charges from at the rate of Rs. per day. (3) Operation Charges. (4) Operation Theater Charges. (I.C.C.U.).00 (5) Anesthesia charges. (Nursing Charges) (6) Visits-a) Routine No 1 at Rs.. per visit Rs. /- Referrals to Dr. No. at Rs. per visit Dr. No. at Rs. per visit Dr. No. at Rs. per visit B) (7) Use of Incubator at Rs. per day for days (8) Use of Monitor at Rs. per dat for days (9) Investigations:- a) Pathology Lab. b) X-ray No. c) ECG at Rs. per ECG d) Other Boyle Machine Charges C) Medicines : Sr.No. Name of Medicine Cost of Medicine 1. List attached Saparately Rs. /-. 2 Rs Injection Charges Rs Total :-.00 Grand Total ( A + B +C) -----
4 " FORM - C " CERTIFICATE OF EXPENSES FOR EMERGENCY MEDICAL TREATMENT TO GOVERNMENT SERVANT ( To be issued by attending private practitioner ) Certificate granted to Shri/Smt./Kumar/Kumari wife/husband/son/daughter/father/mother/sister of Shri/Smt employed in the was treated by the From to as an emergency patient. For the complaints of Vital sign observed Necessary emergency Investigation with results. The Diagnosis was Total expenditure ( Annexure "D" ) incurred for the treatment treatment was Rs. And details of which are given in Form "D" Certified that after the emergency treatment the patient was advised to attend authorised Medical Attendant for treatment. Date Signature Place Name of Doctor Register No. Name of Hospital
5 ANNEXURE -"B" Certificate granted to Shri/Smt./Kumar/Kumari wife/husband/son/daughter/father/mother/sister of Shri/Smt. employed in the CERTIFICATE -"B" (To be issued in the case of patients who are admitted to hospital for treatment) (To be signed by the Medical Officer-in charge of the case at the hospital) I, Dr. hereby certify :- (a) That the patient was admitted to hospital on the advice of my advice (name of medical officer and his Designation.) (b) That the patient has been under treatment at and that the under mentioned medicines prescribed by me in this connection were essential for the recovery/prevention of serious deterioration in the condition of the patient. The medicines prescribed are include in the Category of Medicine in Govt. Resolution. No.MAG 1068/60511/(a)/P, dated 11 the February 1971, No.MAG /(a)/p, dated the 24 the Septe mber 1973 of Annexure-I / Annexure-II/Annexure-III to this Certificate and are not stocked in the ( name of Hospital) for supply to patients and do not include proprietary preparation for which cheaper substances of equal therapeutic value are available, nor preparation which are primarily foods, tonics or disingectants. Sr. Name of Medicines/Appliances and Quantity Total quantity No. their category No. per day required (c) that the patient is/was suffering from and is /was under my treatment from to (d) that the X-ray, laboratory tests, etc. for which an expenditure of Rs. was incurred were necessary and were undertaken on my advice at (name of Hospital or Laboratory) Place :- Date:- Name, Signature and Designation of the Medical Officer-in-charge or the case at the hospital and name of the hospital and stamp.
6 APPENIX - "A" Certificate granted to Shri/Smt./Kumar/Kumari wife /Husband/Son/Daughter/Mother/Father/Sister of Shri/Smt.. employed in the CERTIFICATE -'A' (To be issued in the case of patients who are not admitted to hospital for treatment) I, Dr. hereby certify :- (a) that the patient has been under treatment at Hospital/My consulting room and that the under mentioned medicines prescribed by me in this connection were essential for the recovery/prevention of serious deterioration in the condition of the patient. The medicines prescribed reimbursable under Govt. Resolution, No.MAG=1068/60511/(a) -p, dated 11 th February 1971, MAG-1068/60511/(a) -P,dated 29th September 1973 and No.MAG-1072/60072/S,dated 24 September 1973, are not stocked in the (Name of the Hospital) for supply to patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available for preparations which are primarily foods, tonics or disingectants. Sr. Name of Medicines/Appliances and Quantity Total quantity No. their category No. per day required (b) that the patient is/was suffering from and is /was under my treatment from to (c) that the patient is/was not given prenatal or postnatal treatment. (d) that the X-ray, laboratory tests, etc. for which an expenditure of Rs. was incurred were necessary and were undertaken on my advice at (name of Hospital or Laboratory) Place :- Date:- (e) that the patient did not require/required/hositalisation. Name, Signature and Designation of the Medical Officer-in-charge or the case at the hospital and name of the hospital and stamp.
7 DECLARATION FOR CLAIMING REFUND OF MEDICAL EXPENSES I Shri hereby certify that - (1) The person for whom medical expenses were incurred is wholly dependent upon me. (11) I am a married/unmarried Government Servant and I have less than three living children today. (111) That I had more than 3 living children as on 15th August 1968 and have restricted to that number so far. Signature of Government Servant. Designation : C E R T I F I C A T E 1. Certified that the size of the family of Shri has not exceeded three living children. 2. Certificate that size of the family of O R Shri/Smt No.MR-1082/CS, General Administration Department, Mantralaya, Bombay Dated : as on 15th August 1968, was living child and that size has not been exceeded. 3. Certified that the persons for whom the reimbursement of medical expenses have been claimed by Shri/Smt./Kum ar fully dependent upon him/her. 4. He/She/They is are eligible for medical reimbursement
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gpatpa.com or by calling 915-887-3420. Important Questions
Health Alliance Plan. Coverage Period: 01/01/2015-12/31/2015. document at www.hap.org or by calling 1-800-422-4641.
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://apps.cignabehavioral.com/web/acref/pmrscontroller?cat=initial
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.summitamerica-ins.com/wscc or by calling 1-800-955-1991.
You can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert]. Important Questions
Important Questions Answers Why this Matters:
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Monumental Life Insurance Company: Bennington College Student Injury and Sickness Plan Coverage Period: 08/15/2013 08/15/2014
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bollingercolleges.com/bennington or by calling 1-866-267-0092.
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at:m www.mykyhc.org or by calling: 1-855-OUR-KYHC. Important
You can see the specialist you choose without permission from this plan.
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TATA AIG General Insurance Company Limited Address CLAIM FORM
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