1. Name and designation of Government Servant (In Block Letters) (i) Whether married or unmarried
|
|
|
- Britney Melton
- 8 years ago
- Views:
Transcription
1 Application form for claiming refund of medical expenses incurred in connection with medical attendance and/or treatment of Centeral Government servant and their families for medical attendance/ treatment taken both form an authorized medical attendant and a Hospital 1. Name and designation of Government Servant (In Block Letters) (i) Whether married or unmarried (ii) If married, the place where wife/husband is employed.. 2. Office in which employed 3. Pay of the Government servant as defined in the Fundamental Rules and any other emoluments, which should be shown separately Place duty. 5. Actual residential address Name of the patient and his/her relationship to the Government servant N.B. In the case of children state age also. 7. Place at which the patient fell ill.. 8. Details of the amounts claimed. I. Medical Attendance (i) 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 the free paid for each consultation..
2 (c) the number and dates of injection and the free paid for each injection (d) whether consultation and/or injection where had at the hospital, at the consulting room of the medical officer or at the residence of the patient (ii) Charges for Pathological, Bacteriological, Radiological or other similar tests undertaken during diagnosis indicating (a) the name of the hospital or laboratory where undertaken; and (b) whether the tests were under taken on the advice of the authorized medical attendant. If so, a certificate to that effect should be attached (iii) Cost of medicines purchased from the market (Case memos and the essentiality certificates should be attached) II. Hospital Treatment --- Name of the hospital... Charges for hospital treatment, indicating separately the charges for, -- (i) Accommodation (State whether it was according to the status or pay of the Government servant and in cases where the accommodation is higher than the status of the Government servant, a certificate should be attached to the effect that the accommodation to which he was entitled was not available) (ii) Diet (iii) Surgical operation of medical treatment or confinement (iv) Pathological, bacteriological Radiological or other similar tests, - Indicating ---- (a) The name of the hospital or loboratory at which undertaken; and (b) Whether undertaken on the advice of the medical officer in charge
3 of the case at the hospital. If so, a certificate to that effect should be attached - (v) Medicines (vi) Special medicines. (Cash memos and the Essentiality Certificate should be attached) (vii) Ordinary nursing (viii) Special nursing, i.e., nurses, specially engaged for the patient. State whether they are employed on the advice of the Medical Officer in charge of the case at the hospital or at the request of the Government servant or patient. In the former case a certificate form the Medical Officer in charge of the case and countersigned by the Medical Superintendent of the hospital should be attached. (ix) Ambulance charges (State the journey --- to and fro undertaken (x) Any other charges, e.g., charges for electric light, fan, heater, air conditioning, etc. State also whether the facilities referred to are a part of the facilities normally provided to all patents and no choice was left to the patient. Note If the treatment was received by the Government servant at his residence under Rule 7 of the CS (MA) Rules, 1944, give particulars of such treatment and attach a certificate from the Authorized Medical Attendant as required by these rules. Note If the treatment was received at a hospital other than a Government hospital, necessary details and the certificate of the Authorized Medical Attendant that the requisite treatment was not available in any nearest Government hospital should be furnished. III Consultation with Specialist Fee paid to Specialist or a Medical Officer other than the Authorized Medical Attendant, indicating (a) the name and designation of the Specialist or Medical Officer consulted and the hospital to which attached..
4 (b) number and dates of consultations and the fees charged for each consultation. (c) whether consultation had was at the hospital, at the consulting room of the Specialist or Medical Officer or at the residence of the Patient; and (d) whether the Specialist or Medical Officer was consulted on the advice of the Authorized Medical Attendant and the prior approval of the Chief Administrative Medical Officer of the State was obtained. If so, a certificate to that should be attached. 9. Total amount claimed Rs. 10. Less advance taken on. Rs. 11. Net amount claimed Rs. 12. List of enclosures Rs. DECLARTAION TO BE SIGNED BY THE GOVERNMENT SERVANT I hereby declare that the statements in the application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me. Date Signature of the Government servant and Office to which attached
5 Application form for claiming refund of medical expenses incurred in connection with medical attendance/treatment of Central Government servants or their families for treatment in a Hospital 1. Name and designation of Government Servant (In Block Letters) (i) Whether married or unmarried (ii) If married, the place where wife/husband is employed.. 2. Office in which employed 3. Pay of the Government servant as defined in the Fundamental Rules and any other emoluments, which should be shown separately. 4. Place duty. 5. Actual residential address Name of the patient and his/her relationship to the Government servant N.B. In the case of children state age also. 7. Place at which the patient fell ill.. 8. Details of the amounts claimed. I. Hospital Treatment --- Name of the hospital... Charges for hospital treatment, indicating separately the charges for, -- (i) Accommodation (State whether it was according to the status or pay of the Government servant and in cases where the accommodation is higher than the status of the Government servant, a certificate should be attached to the effect that the accommodation to which he was entitled was not available)
6 (ii) Diet (iii) Surgical operation of medical treatment (iv) Pathological, bacteriological Radiological or other similar tests, - Indicating ---- (a) The name of the hospital or loboratory at which undertaken; and (b) Whether undertaken on the advice of the medical officer in charge of the case at the hospital. If so, a certificate to that effect should be attached (v) Medicines (vi) Special medicines. (Cash memos and the Essentiality Certificate should be attached) (vii) Ordinary nursing (viii) Special nursing, i.e., nurses, specially engaged for the patient. State whether they are employed on the advice of the Medical Officer in charge of the case at the hospital or at the request of the Government servant or patient. In the former case a certificate form the Medical Officer in charge of the case and countersigned by the Medical Superintendent of the hospital should be attached. (ix) Ambulance charges (State the journey --- to and fro undertaken (x) Any other charges, e.g., charges for electric light, fan, heater, air conditioning, etc. State also whether the facilities referred to are a part of the facilities normally provided to all patents and no choice was left to the patient... Note If the treatment was received by the Government servant at his residence under Rule 7 of the CS (MA) Rules, 1944, give particulars of such treatment and attach a certificate from the Authorized Medical Attendant as required by these rules. Note If the treatment was received at a hospital other than a Government hospital, necessary details and the certificate of he Authorized
7 Medical Attendant that the requisite treatment was not available in any nearest Government hospital should be furnished. III Consultation with Specialist Fee paid to Specialist or a Medical Officer other than the Authorized Medical Attendant, indicating (a) the name and designation of the Specialist or Medical Officer consulted and the hospital to which attached.. (b) number and dates of consultations and the fees charged for each consultation... (c) whether consultation was had at the hospital, at the consulting room of the Specialist or Medical Officer or at the residence of the Patient; and (d) whether the Specialist or Medical Officer was consulted on the advice of the Authorized Medical Attendant and the prior approval of the Chief Administrative Medical Officer of the State was obtained. If so, a certificate to that should be attached. 9. Total amount claimed Rs. 10. Less advance taken on. Rs. 11. Net amount claimed Rs. 12. List of enclosures Rs. DECLARTAION TO BE SIGNED BY THE GOVERNMENT SERVANT I hereby declare that the statements in the application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me. Date. Signature of the Government servant and Office to which attached
8 Application form for claiming refund of medical expenses incurred in connection with medical attendance and/or treatment of Central Government servants and their families - For Medial Attendance by Authorized Medial Attendant 1. Name and designation of Government Servant (In Block Letters) (i) Whether married or unmarried (ii) If married, the place where wife/husband is employed.. 2. Office in which employed 3. Pay of the Government servant as defined in the fundamental Rules and any other emoluments, which should be shown separately. 4. Place duty. 5. Actual residential address Name of the patient and his/her relationship to the Government servant N.B. In the case of children state age also. 7. Place at which the patient fell ill.. 8. Details of the amounts claimed. I. Medical Attendance (i) 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 the free paid for each consultation.. (c) the number and dates of injection and the free paid for each
9 injection (d) whether consultation and/or injection where had at the hospital, at the consulting room the medical officer or at the residence of the patient (ii) Charges for Pathological, Bacteriological, Radiological or other similar tests undertaken during diagnosis indicating (a) the name of the hospital or laboratory where undertaken; and (b) whether the tests were under taken on the advice of the authorized medical attendant. If so, a certificate to that effect should be attached (iii) Cost of medicines purchased from the market (Case memos and the essentiality certificates should be attached) II. Consultation with Specialist - Fee paid to Specialist or a Medical Officer other than the Authorized Medical Attendant, indicating - (a) the name and designation of the Specialist or Medical Officer consulted and the hospital to which attached.. (b) number and dates of consultations and the fees charged for each consultation. (c) whether consultation was had at the hospital, at the consulting room of the Specialist or Medical Officer or at the residence of the Patient; and (d) whether the Specialist or Medical Officer was consulted on the advice of the Authorized Medical Attendant and the prior approval of the Chief Administrative Medical Officer of the State was obtained. If so, a certificate to that should be attached. 9. Total amount claimed Rs. 10. Less advance taken on. Rs. 11. Net amount claimed Rs. 12. List of enclosures Rs.
10 DECLARTAION TO BE SIGNED BY THE GOVERNMENT SERVANT I hereby declare that the statements in the application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me. Date. Signature of the Government servant and Office to which attached
11 ESSENTIALITY CERTIFICATE CERTIFICATE 'A' Under Central Service (Medical Attendance) Rules (To be completed in the case of patients who are not admitted to hospital for treatment) Certificate granted to Mrs./Mrs./Miss. wife/son/daughter of Mr. employed in the. I, Dr. hereby certify (a) that I charges and received Rs. for consultation on (dates to be given) at my consulting room/at the residence of the patient; (b) that I charged and received Rs. for administering intravenous/intra-muscular/subcutaneous injection on (dates to be given ) at my consulting room/the residence of the patient; (c) that the injection administered were not/were for immunising or prophylactic purposes; (d) that the patient has been under treatment at hospital/my consulting room and that the undermentioned medicines prescribed by me in this connection were essential for the recovery/prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the (name of hospital) for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparations which are primarily foods, toilets or disinfectants. Names of medicines Price
12 -2- (e) that the patient is/was suffering from and is /was under my treatment from to ; (f) that the patient is/was not given pre-natal or post-natal treatment ; (g) that the X-ray, laboratory test etc., for which an expenditure of Rs. was incurred was necessary and were undertaken on my advice at (name of the hospital or laboratory); (h) that I referred the patient to Dr. for Specialist consultation and that the necessary approval of the (name of the Chief Administrative Officer of the State) as required under the rules was obtained; (i) that the patient did not require/required hospitalisation. Dated: Signature of AMA/Designation of the Medical Officer and Hospital (Dispensary to which attached)
13 ESSENTIALITY CERTIFICATE CERTIFICATE 'B' Under Central Service (Medical Attendance) Rules (To be completed in the case of patients who are admitted to hospital for treatment) Certificate granted to Mrs./Mrs./Miss. wife/son/daughter of Mr. employed in the Central Pollution Control Board. PART-A I, Dr. hereby certify (a) that the patient was admitted to hospital on the advice of (name of the Medical Officer)/on my advice: (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 are not stocked in the (name of the hospital) for supply to private patients and do no include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparation which are primarily foods, toilets or disinfectants: Names of medicines Price (c) that the injections administered were/were not for immunizing or prophylactic purposes: (d) that the patient is/was suffering from and is/was under treatment from to ;
14 -2- (e) that the X-ray, laboratory test etc., for which an expenditure of Rs. was incurred was necessary and were undertaken on my advice at (name of the hospital or laboratory); (f) that I called on Dr. for Specialist consultation and that the necessary approval of the ) Name of the Chief Administrative Medical Officer of the State) as required under the rules, was obtained. PART-B Signature and Designation of the Medical Officer in charge of the case at the hospital I certify that the patient has been under treatment at the hospital and that the service of the special nurses for which an expenditure of Rs. was incurred, vide bills and receipts attached, were essential for the recovery/prevention of serious deterioration in the condition of the patient. COUNTERSIGNED Signature and Designation of the Medical Officer in charge of the case at the hospital *I certify that the patient has been under treatment at the hospital and that the facilities provided were the minimum which were essential for the patient s treatment. Place: Medical Superintendent Hospital Note:- Certificates not applicable should be struck off. Certificate (d) is compulsory and must be filled in by the Medical Officer in all cases. *The minimum facilities certificate may be signed either by the Medical Superintendent of the Hospital concerned or another Gazetted Medical Officer who has been authorized in this behalf by the Medical Superintendent.
15
16
Charges for pathological, bacteriological, radiological or other similar tests undertaken during diagnosis.
APPENDIX-XIII FORM OF APPLICATION FOR MEDICAL CLAIMS Med.97 For of application for claiming refund of medical expenses incurred in connection with medical attendance and/or treatment of Central Government
FORM OF APPLICATIONS FOR MEDICAL CLAIMS
FORM OF APPLICATIONS FOR MEDICAL CLAIMS MEDICAL 97 FORM FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDENCE AND/OR TREATMENT OF CENTRAL GOVT SERVANT
DOCUMENTS REQUIRED FOR SUBMISSION OF MEDICAL BILLS. The following documents should be sent along with the medical reimbursement claims:
DOCUMENTS REQUIRED FOR SUBMISSION OF MEDICAL BILLS The following documents should be sent along with the medical reimbursement claims: 1. Individual's representation. 2. Med. 97 in duplicate. 3. Certificate
TRANSMISSION CORPORATION OF ANDHRA PRADESH LIMITED
TRANSMISSION CORPORATION OF ANDHRA PRADESH LIMITED Claim for Reimbursement of Medical Charges For In-Patient Treatment (Check List to be signed and furnished by the Board Employee) Indicate Yes or No In
10. Total amount claimed. Rs. 11. List of enclosures. Hospital Bill cash Memo. 12. Size of family i.e.living children as on 15.8.1968 and thereafter
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
Central University of Rajasthan, Ajmer. Medical Reimbursement Rules for employees of the University (University Ordinance 29)
, Ajmer Medical Reimbursement Rules for employees of the University CONTENTS 1. Short Title and Extent of Application 2. Definitions 3. Medical Attendance 4. Travelling allowance for medical attendance
CENTRAL SERVICES (MEDICAL ATTENDANCE) RULES, 1944
CENTRAL SERVICES (MEDICAL ATTENDANCE) RULES, 1944 PREAMBLE In exercise of the powers conferred by sub-section (2) of section 241, read with sub-section (3) of section 313 of the Government of India Act,
NORTHERN POWER DISTRIBUTION COMPANY OF A.P. Ltd. CORPORATE OFFICE :: WARANGAL - 506 004.
NORTHERN POWER DISTRIBUTION COMPANY OF A.P. Ltd. CORPORATE OFFICE :: WARANGAL - 506 004. Circular Memo. No. CGM(HRD)/JS/GM(IR)/AS-IR/PO.F/F.No. 18/12. Dt: 14-12-12. Sub : AP NPDCL / Wgl - Medical Reimbursement
GUIDELINES FOR AVAILING INDOOR/OUTDOOR FACILITIES
GUIDELINES FOR AVAILING INDOOR/OUTDOOR FACILITIES INTRODUCTION 1. The following categories are eligible for availing the medical facilities:- (a) Employee serving in the organization. (b) Unemployed and/or
KERALA*\".,-TffiH:ffit MEDICAL ATTENDAI{CE
eppenafru KERALA*\".,-TffiHffit MEDCAL ATTENDA{CE, {Proforma to iefr,lkn up by the Authorised Medical Attendant when a patimt is referred lo other Hospilals within/outside State). 1. Nasrc and address
CENTRAL INSTITUTE OF TECHNOLOGY KOKRAJHAR MEDICAL RULES SPECIFIC TO EMPLOYEES OF CIT KOKRAJHAR
Annexure-VII MEDICAL RULES SPECIFIC TO EMPLOYEES OF CIT KOKRAJHAR 1 MEDICAL RULES 1. Definitions 1.1. "Hospital" means a hospital approved by the CIT for the purpose of these rules and included in the
Rules for Medical Attendance, Treatment and Reimbursement
NATIONAL INSTITUTE OF TECHNOLOGY MEGHALAYA 1. Eligibility Rules for Medical Attendance, Treatment and Reimbursement I. Staff and their Families 1.1 Staff members of the Institute and members of their families
MEDICAL ATTENDANCE AND TREATMENT RULES
MEDICAL ATTENDANCE AND TREATMENT RULES 1.0 DEFINITIONS 2.0 MEDICAL TREATMENT 3.0 REIMBURSEMENT OF MEDICAL BILLS 4.0 HOSPITAL TREATMENT 5.0 CHARGES FOR PATHOLOGICAL AND OTHER EXAMINATIONS 6.0 REIMBURSEMENT
1.(a). Name of the Retired Employee : (b). Designation & Employee No. : 2. Name of the Spouse :
Annexure-I NMDC LTD., Proforma for claiming half yearly reimbursement of O P Treatment expenses on self-certification basis (for use by those who are not availing PCT 1.(a). Name of the Retired Employee
CONTRIBUTORY MEDICAL SCHEME
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY Thiruvananthapuram 695011(Kearala) CONTRIBUTORY MEDICAL SCHEME 1. Title and Scope: The Scheme shall be called SCTIMST Employees Contributory
Medical facilities as detailed hereunder are available to the employee and his family.
CHAPTER 16 MEDICAL AID AND EXPENSES 16.1 ELIGIBILITY Medical facilities as detailed hereunder are available to the employee and his family. 16.1.1 Definition of family a) 'The expression 'family' of an
Total and Permanent Disability claim form
Total and Permanent Disability claim form 1. Notice Of Claim Written notice of claim must be given to AXA Life within 90 days from the date of disability certified by a specialist in the relevant field.
GROUP BENEFITS PLAN CANADIAN EARLY RETIREES EFFECTIVE JANUARY 1, 2003
GROUP BENEFITS PLAN CANADIAN EARLY RETIREES EFFECTIVE JANUARY 1, 2003 A Medical Benefits Plan for Early Retirees This information booklet has been prepared to give you an informal summary of the main features
CENTRAL GOVERNMENT HEALTH SCHEME CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS
CENTRAL GOVERNMENT HEALTH SCHEME CHECK LIST FOR REIMBURSEMENT OF MEDICAL CLAIMS 1. CGHS Token No. and place of issue : 2. Validity of CGH Card (For pensioners)& : from to. Entitlement : Pvt. / Semi Pvt./General
ROYAL INSURANCE CORPORATION OF BHUTAN LTD HEAD OFFICE: THIMPHU
ROYAL INSURANCE CORPORATION OF BHUTAN LTD HEAD OFFICE: THIMPHU GUIDELINES OF THE PRIVATE PROVIDENT FUND SCHEME (PPF) 2011 (SAVE WHILE YOU EARN) TRUSTEE ROYAL INSURANCE CORPORATION OF BHUTAN LIMITED TABLE
Travel Insurance Claim Form
Jetstar Travel Travel Insurance Insurance Claim Form IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for
(To be routed through the State Government/ Union Territory Administration)
Matching Scheme of Assistance forwards purchase of storage materials, reading room furniture and library equipment like card cabinet, fire extinguisher etc., including copier Application for grant under
How To Write A Bill To Allow A Nurse To Write Prescriptions For Drugs
131st General Assembly Regular Session S. B. No. 110 2015-2016 Senator Burke A B I L L To amend sections 4723.07, 4723.48, and 4731.72 and to enact section 4723.489 of the Revised Code to authorize administration
Once we have received all the above required documents, we will process your claim and inform you of the outcome as soon as possible.
ACCIDENT CLAIM FORM Dear Claimant, We are sorry to learn of your accident. In order for us to process your claim, we require the following: 1) Claimant s Statement. 2) 1 Clinical Abstract Application Form.
TABLE 120 - SCHEDULE OF COVER and POLICY DOCUMENT
TABLE 120 - SCHEDULE OF COVER and POLICY DOCUMENT Sections 1,2, 3, 7 and 8 only Contents: Section 1 Section 2 Section 3 Section 7 Section 8 In-Hospital (In-Patient) Expenses for Sickness and Injury, including
No. 11058/03/2012-AIS-III Government of India Ministry of Personnel, Public Grievances & Pensions (Department of Personnel & Training)
No. 11058/03/2012-AIS-III Government of India Ministry of Personnel, Public Grievances & Pensions (Department of Personnel & Training) North Block, New Delhi Dated the 2 nd September, 2013 To, Chief Secretaries
Your People, Protected. Sports group Personal Accident Claim Form
Your People, Protected Sports group Personal Accident Claim Form Sports group Personal Accident/Claim Form 2 Claim Form Dear Member, IMPORTANT INFORMATION, relevant to YOUR Claim, is contained on this
Creditor Disability Claim Application Kit
Life and Health Claims Dept. Creditor Disability Claim Application Kit The Application Kit contains: an instruction sheet plus forms that need to be completed in order to apply for disability benefits;
Travel and Cancellation Policy Claim Form
Travel and Cancellation Policy Claim Form If any expenses that you are claiming are also insured elsewhere, you should submit your claim to that company first (e.g. under a medical, bicycle, caravan, annual
ADVANCED PRACTICE NURSING WRITTEN COLLABORATIVE AGREEMENT
ADVANCED PRACTICE NURSING WRITTEN COLLABORATIVE AGREEMENT A. ADVANCED PRACTICE NURSE INFORMATION 1. NAME: 2. ILLINOIS RN LICENSE NUMBER: ILLINOIS APN LICENSE NUMBER: ILLINOIS MID-LEVEL PRACTIONER LICENSE
PROFESSIONAL LIABILITY INSURANCE FOR CHARITIES, ASSOCIATIONS, SOCIETIES, CLUBS AND THE LIKE
Important notice: PROFESSIONAL LIABILITY INSURANCE FOR CHARITIES, ASSOCIATIONS, SOCIETIES, CLUBS AND THE LIKE 1. This is a proposal for a contract of insurance, in which Proposer or you/your means the
TATA AIG General Insurance Company Limited Address CLAIM FORM
CLAIM FORM CLAIM FORM PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability SECTION A DETAILS OF PRIMARY INSURED a) Policy No b) Sl. No/ Certificate
Sports Injury Claim Form
Sports Underwriting Australia Sports Underwriting Australia Claims Department PO E: liabilityclaims@sportsunderwriting.com.au Box 2717, Taren Point. NSW, 2229 Tel: Ph: 1300 363 363 413 413 Fax: +61 2 9524
SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form
SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form Dear Member, Thank you for your Claim Form request. This letter contains important information relevant to your
PERSONAL ACCIDENT CLAIM FORM
PERSONAL ACCIDENT CLAIM FORM OFFICE USE ONLY Claim Number Reference Number Complete this form if: You have suffered an accident, outside working hours and wish to claim weekly, capital and/or broken bones
Schneps, Leila; Colmez, Coralie. Math on Trial : How Numbers Get Used and Abused in the Courtroom. New York, NY, USA: Basic Books, 2013. p i.
New York, NY, USA: Basic Books, 2013. p i. http://site.ebrary.com/lib/mcgill/doc?id=10665296&ppg=2 New York, NY, USA: Basic Books, 2013. p ii. http://site.ebrary.com/lib/mcgill/doc?id=10665296&ppg=3 New
TAMIL NADU LEGISLATIVE ASSEMBLY (MEDICAL ATTENDANCE AND TREATMENT) RULES, 1964
TAMIL NADU LEGISLATIVE ASSEMBLY (MEDICAL ATTENDANCE AND TREATMENT) RULES, 964 50 THE TAMIL NADU 3 LEGISLATIVE ASSEMBLY (MEDICAL ATTENDANCE AND TREATMENT) RULES, 964. [G.O. Ms. No. 38, Education and Public
NURSING HOMES OPERATION REGULATION
Province of Alberta NURSING HOMES ACT NURSING HOMES OPERATION REGULATION Alberta Regulation 258/1985 With amendments up to and including Alberta Regulation 164/2015 Office Consolidation Published by Alberta
RECIPROCAL REGISTRATION FORM PROFORMA-7 MADHYA PRADESH MEDICAL COUNCIL: BHOPAL
Allotted Registration No. MP-... Date:... (FOR OFFICE USE ONLY) Price: Rs. 200.00 Receipt No... Dt... Collection No.... RECIPROCAL REGISTRATION FORM PROFORMA-7 MADHYA PRADESH MEDICAL COUNCIL: BHOPAL APPLICATION
1 Please ensure that the club Secretary/Treasurer completes the Official Report section of the claim form.
Playeraccident claimform Our Head Office and registered address is: Sportscover Europe Ltd 3 rd Floor, PO Box HQ420, St Helen s, 1 Undershaft, London, EC3P 3DQ Registered in England and Wales. 3726678
CLAIM FOR WORKERS COMPENSATION
CLAIM FOR WORKERS COMPENSATION Seafarers Rehabilitation and Compensation Act 1992 Information about claiming workers compensation In this document, all references to the employer mean the employer against
Tata AIG Life Insurance Company Limited (hereinafter called Tata AIG or the Company, whichever is applicable)
Policy.: Claim.: Tata AIG Life Insurance Company Limited (hereinafter called Tata AIG or the Company, whichever is applicable) HOSPITALIZATION CLAIM FORM Office Agency Code Agent Code PART I (To be completed
How To Write A Claim For Hospital Expenses
In-patient, Day-case & Surgical Out-patient Treatment Claim Form In order to make a claim Affix Hospital Label Here Please answer all the questions below, complete the relevant sections, read and sign
How to File a Stock Market Complaint
Instructions for filing of Complaints against Members/Brokers/Agents of the Stock Exchanges 1. You can file all your complaints regarding stock brokers/agents only on the prescribed form, which is available,
Table 190 - SCHEDULE OF COVER and POLICY DOCUMENT
Table 190 - SCHEDULE OF COVER and POLICY DOCUMENT Sections 1,3, 7 and 8 only Contents: Section 1 Section 3 Section 7 Section 8 In-Hospital (In-Patient) Expenses for Sickness and Injury, including rehabilitation
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
New York State Public Health Law TITLE II-D HEALTH CARE PRACTITIONER REFERRALS
New York State Public Health Law TITLE II-D HEALTH CARE PRACTITIONER REFERRALS Sec. 238. Definitions. 238-a. Prohibition of financial arrangements and referrals. 238-b. Provider requests for payment. 238-c.
Delegation of Services Agreements Change in Regulations
Delegation of Services Agreements Change in Regulations Title 16, Division 13.8, Article 4, section 1399.540 was amended to include several requirements for the delegation of medical services to a physician
GENERAL INSTRUCTIONS TO APPLICANTS
GENERAL INSTRUCTIONS TO APPLICANTS 1. Two complete sets of application form to be submitted to the Indian Mission. 2. Candidate should clearly mention the course and University to which he/she is seeking
GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM
GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM A Member of the OCBC Group CLAIM SUBMISSION PROCEDURES Please read carefully before you complete the attached Claim Form. 1. 2. The Great Eastern Life Assurance
Notice of Accident Claim Form
Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Non-Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident
GOVERNMENT OF RAJASTHAN FINANCE DEPARTMENT (RULES DIVISION) Rajasthan Civil Services (Medical Attendance) Rules, 2013
GOVERNMENT OF RAJASTHAN FINANCE DEPARTMENT (RULES DIVISION) Rajasthan Civil Services (Medical Attendance) Rules, 2013 (Updated upto 07-01-2016) This document is compilation of original orders and amendments.
Notice of Accident Claim Form
Insurer's Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) tice of Accident Claim Form (n-fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance
We are writing further to your request for a claim form and are very sorry to note the circumstances described.
InsureandGo Claims PO Box 5775 Southend-on-Sea Essex SS1 2JY Dear Sir / Madam, TRAVEL INSURANCE CLAIM We are writing further to your request for a claim form and are very sorry to note the circumstances
SAMPLE WRITTEN SUPERVISION AGREEMENT
A. Physician Assistant Information 1. Name: SAMPLE WRITTEN SUPERVISION AGREEMENT 2. Illinois PA License Number: Illinois Mid-Level Practitioner Controlled Substance License Number: Federal Mid-Level Practitioner
Personal Accident / Sickness Claim Form
Personal Accident / Sickness Claim form All relevant sections are to be answered in full. Please print your answers. The company does not admit liability by the issue of this form. It is issued to enable
PERSONAL ACCIDENT CLAIM FORM - MEMBERS
Pony Club Insurance Scheme PERSONAL ACCIDENT CLAIM FORM - MEMBERS Please read this page before completing the Claim Form Dear Member Thank you for your Claim Form request. This letter contains important
GROUP PERSONAL ACCIDENT CERTIFICATE OF CURRENCY
GROUP PERSONAL ACCIDENT CERTIFICATE OF CURRENCY This letter is to certify that our client s policy is current as detailed below and cover has been granted in terms of the Insurer s Standard Policy. The
HEALTH SERVICES [Cap. 550
[Cap. 550 Acts Nos.l2of l952, 10 of 1956, 13 of 1962, Law No. 3 of 1977. Short title. The Department of Health. Appointment of officers, &c. CHAPTER 550 AN ACT TO PROVIDE FOR THE CONSTITUTION AND RESPONSIBILITIES
SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM
SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM The issue or acceptance of this form is not construed as an admission of liability on the part of the Company. Please print clearly. To avoid delays please
How To Claim From Safari Safari Insurance In Korea
Date sent to us: / /20 Claim Reference Number (if known): Please answer all relevant questions on the claim form. Leaving items blank, using ticks, dashes and n/a may result in us returning the claim form
NOTIFICATION. Chapter 1 Preliminary
GOVERNMENT OF MIZORAM FINANCE DEPARTMENT NOTIFICATION Dated Aizawl, the 29 th March, 2011 No.B.14015/31/2008-F.IF&SL- Whereas section 28 of the Mizoram Money Lenders and Accredited Loan Providers (Regulation)
ARTICLE 8. ASSISTED LIVING FACILITIES
Section R9-10-801. R9-10-802. R9-10-803. R9-10-804. R9-10-805. R9-10-806. R9-10-807. R9-10-808. R9-10-809. R9-10-810. R9-10-811. R9-10-812. R9-10-813. R9-10-814. R9-10-815. R9-10-816. R9-10-817. R9-10-818.
How To Get A Small Business License In Australia
1 L.R.O. 2007 Small Business Development CAP. 318C CHAPTER 318C SMALL BUSINESS DEVELOPMENT ARRANGEMENT OF SECTIONS SECTION 1. Short title. 2. Interpretation. 3. Small business. 4. Approved small business
REVERSE MORTGAGE LOAN APPLICATION FORM
REVERSE MORTGAGE LOAN APPLICATION FORM Recent Photo of Main Applicant Recent Photo of Spouse (wherever applicable) INSTRUCTIONS: 1. Please use BLOCK LETTERS 2. All details must be filled in. If not applicable,
OFFICE MEMORANDUM. Page 1 of 5
Most Immediate No. II/21022/58(97)/2011-FCRA-I Government of India/Bharat Sarkar Ministry of Home Affairs/Grih Mantralaya Foreigners Division (FCRA Wing) ***** Jaisalmer House 26 Mansingh Road New Delhi
Community Underwriting Personal Accident Claim Form
Community Underwriting Personal Accident Claim Form About Community Underwriting Community Underwriting Agency Pty Ltd (Community Underwriting) acts under a binding authority as Agent for Berkley Insurance
Claim for Long Term Disability Benefit
Public Service Management Insurance Plan Claim for Long Term Disability Benefit The National Life Assurance Company of Canada Group Policy No. G68-1400 A CLAIM CONSISTS OF FORM 5945 (PARTS 1 AND 2) AND
Health Care Act 2008. Contents. South Australia. Part 1 Preliminary. Part 2 Minister and Chief Executive. Part 3 Health Performance Council
Version: 16.9.2012 South Australia Health Care Act 2008 An Act to provide for the administration of hospitals and other health services; to establish the Health Performance Council and Health Advisory
GUIDELINES FOR TRAVEL GRANT SCHEME FOR COLLEGE TEACHERS/COLLEGELIBRARIANS/VICE CHANCELLORS/COMMISSIONMEMBERS AND UGC OFFICERS XII PLAN (2012-2017)
GUIDELINES FOR TRAVEL GRANT SCHEME FOR COLLEGE TEACHERS/COLLEGELIBRARIANS/VICE CHANCELLORS/COMMISSIONMEMBERS AND UGC OFFICERS XII PLAN (2012-2017) UNIVERSITY GRANTS COMMISSION BAHADUR SHAH ZAFAR MARG NEW
Sports Injury Claim Form
Sports Underwriting Australia Sports Injury Claim Form Sports Underwriting Australia Claims Department PO Box 2717, Taren Point. NSW, 2229 Tel: 1300 363 413 Fax: 02 9524 9003 Email: paclaims@sportsunderwriting.com.au
BERMUDA GOVERNMENT EMPLOYEES (HEALTH INSURANCE) (BENEFITS) ORDER 1997 BR 32 / 1997
QUO FA T A F U E R N T BERMUDA GOVERNMENT EMPLOYEES (HEALTH INSURANCE) (BENEFITS) ORDER 1997 BR 32 / 1997 [made under section 12 of the Government Employees (Health Insurance) Act 1986 and brought into
(Chapter No. not allocated yet) SOCIAL SECURITY ORDINANCE
(Chapter No. not allocated yet) SOCIAL SECURITY ORDINANCE Non-authoritative Consolidated Text This is not an authoritative revised edition for the purposes of the Revised Edition of the Laws Ordinance;
NEW BUSINESS MEMO GUARANTEED ISSUE WHOLE LIFE
NEW BUSINESS MEMO GUARANTEED ISSUE WHOLE LIFE Regular Mail: United Home Life Insurance Company P.O. Box 7192 Indianapolis, IN 46207-7192 FAX Number: 317-692-7711 Telephone: 800-428-3001 Overnight Mail:
Sports Injury Claim Form
Sports Injury Claim Form Sports Underwriting Australia Claims Department PO Box 2717, Taren Point. NSW, 2229 Tel: 1300 363 413 Fax: 02 9524 9003 Email: sua@au.innovation-group.com Members Name: Address:
APPENDIX-I [Rule 3(1)]
![APPENDIX-I [Rule 3(1)]](/thumbs/27/10285609.jpg "APPENDIX-I [Rule 3(1)]")
APPENDIX-I [Rule 3(1)] Return of Assets and Liabilities on First Appointment or as on the 31 st March, 20..* (Under Sec 44 of the Lokpal and Lokayuktas Act, 2013) 1. Name of the Public servant in full
Combined Insurance Claim Form
Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.
Program Manual & Application Form Revised: 03/16/2015
Lackawanna County SBA Loan Fee Waiver Program Program Manual & Application Form Revised: 03/16/2015 Prepared by Lackawanna County Department of Economic Development Table of Contents Introduction... 2
Provider Manual Section 4.0 Office Standards
Provider Manual Section 4.0 Office Standards Table of Contents 4.1 Appointment Scheduling Standards 4.2 After-Hours Telephone Coverage 4.3 Member to Practitioner Ratio Maximum 4.4 Provider Office Standards
Notice of Accident Claim Form
Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance
INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM
INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM Dear claimant, We are sorry to learn about your disability. In order for us to process your claim, we require the following: (1) Claimant s Statement
CPSM DRAFT STATEMENT ON PHYSICIAN ASSISTED DYING OCTOBER 15, 2015
CPSM DRAFT STATEMENT ON PHYSICIAN ASSISTED DYING OCTOBER 15, 2015 BACKGROUND The Supreme Court of Canada (SCC) declared that as of February 6, 2016 it is legal for a physician to assist a competent adult
The BVZ is important for a uniform access to and maintaining and where possible improving the quality of health care.
A basic health insurance On February 1, 2013, the basic healthcare insurance (BVZ) was introduced for all residents of Curaçao. The basic healthcare insurance, as regulated in the Basic healthcare Act,
INDEPENDENT CONTRACTOR CONSULTING AGREEMENT INSTRUCTIONS, ROUTING AND APPROVAL COVER SHEET
INDEPENDENT CONTRACTOR CONSULTING AGREEMENT INSTRUCTIONS, ROUTING AND APPROVAL COVER SHEET I. The requesting department should complete the following Independent Contractor Consulting Agreement ( Agreement
We are writing further to your request for a claim form and are very sorry to note the circumstances described.
PO Box 5775 Southend-on-Sea Essex SS1 2JY Dear Sir/Madam Travel Insurance Claim We are writing further to your request for a claim form and are very sorry to note the circumstances described. In order
Policy & Procedures:... Travel Insurance Cover Note... 5 Appendix 1: Form FT1... 3 Appendix 2: Form FT2... 7 Appendix 3: Form FT3...
National Shared Services Directorate HSE Foreign & Domestic Travel Policy Document 1 1. Policy & Procedures:... Error! Bookmark not defined. 1.1 Overview... 3 1.2 Purpose... 3 1.3 Authorisation for Foreign
GUIDELINES FOR APPRENTICESHIP BY COMPANY SECRETARIES IN PRACTICE, 1985, AMENDED UPTO 22.09.2013
GUIDELINES FOR APPRENTICESHIP BY COMPANY SECRETARIES IN PRACTICE, 1985, AMENDED UPTO 22.09.2013 1. TITLE: These guidelines may be titled as Guidelines for Apprenticeship Training by Company Secretaries
Long-Term Care Insurance Outline of Coverage [Home Health Care Indemnity Policy Form HHC-TX (Rev.)]
![Long-Term Care Insurance Outline of Coverage [Home Health Care Indemnity Policy Form HHC-TX (Rev.)]](/thumbs/24/2751290.jpg "Long-Term Care Insurance Outline of Coverage [Home Health Care Indemnity Policy Form HHC-TX (Rev.)]")
601 E. BRITTON ROAD OKLAHOMA CITY, OKLAHOMA 73114 TOLL FREE TELEPHONE NUMBER: 1-800-654-9106 Long-Term Care Insurance Outline of Coverage [Home Health Care Indemnity Policy Form HHC-TX (Rev.)] Reserve
SUDBURY CATHOLIC DISTRICT SCHOOL BOARD
SUDBURY CATHOLIC DISTRICT SCHOOL BOARD 165A D YOUVILLE STREET, SUDBURY, ONTARIO P3C 5E7 tel. (705) 673-5620 fax (705) 673-6670 http://www.scdsb.edu.on.ca ADMINISTRATIVE PROCEDURE AND GUIDELINE APG #CS21
IV Semester M.B.A. (Part Time) Degree Examination, July 2009 (2006 Scheme) MANAGEMENT INFORMATION SYSTEM
*3726* (Pages : 7) 3726 Reg. No. :... Name :... IV Semester M.B.A. (Part Time) Degree Examination, July 2009 (2006 Scheme) MANAGEMENT INFORMATION SYSTEM Time : 3 Hours Max. Marks : 60 PART A Write short
Karnataka Private Medical Establishments Act. 2007
Karnataka Private Medical Establishments Act. 2007 Dr. S. B. N.PRAKASH Former district and sessions judge, Now the professor of Law. National Law school of India University. Bangalore. What the law stated
Important notice each incident requires a separate claim form. Postal Address Risk/Cost Centre
Travel Claim Form 221 St George s Terrace, Perth GPO Box K837 Perth WA 6842 Telephone (08) 9264 3333 Facsimile (08) 9322 1557 Website www.riskcover.wa.gov.au Important notice each incident requires a separate
Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests)
A AmeriHealth EPO Individual Summary of Benefits Value Network IHC EPO $30/50% Benefit Network Non network Benefit Period+ Calendar year Individual deductible $2,500 Family deductible $5,000 50% Individual
SsSECURITIES AND EXCHANGE COMMISSION OF PAKISTAN - - - - NOTIFICATION
SsSECURITIES AND EXCHANGE COMMISSION OF PAKISTAN - - - - Islamabad, the December 14, 1999 NOTIFICATION S.R.O. 1337 (I)/99.- In exercise of the powers conferred by section 506 of the Companies Ordinance,
FLORIDA PERSONAL INJURY PROTECTION
POLICY NUMBER: COMMERCIAL AUTO CA 22 10 01 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FLORIDA PERSONAL INJURY PROTECTION For a covered "auto" licensed or principally garaged in,
SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company
Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au
Declaration to be submitted by directors in the Applicant Company 1
Form SNBFI/D1 Name of the Applicant Company: Declaration to be submitted by directors in the Applicant Company 1 1. Personal Details 1.1 Full name: 1.2 National Identity Card number: 1.3 Passport number:
Claim form for medical treatment reimbursements
Claim form for medical treatment reimbursements Please complete clearly in block capitals. Information about how to complete can be found on the reverse of this form. Your claim will be processed by InterGlobal
INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM
INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM Dear claimant, We are sorry to learn about your hospitalization. In order for us to process your claim, we require the following: (1) Claimant s Statement (2)
CERTIFICATE OF DESIGNATION OF PREFERRED STOCK OF LIGHTING SCIENCE GROUP CORPORATION. To Be Designated Series B Preferred Stock
CERTIFICATE OF DESIGNATION OF PREFERRED STOCK OF LIGHTING SCIENCE GROUP CORPORATION To Be Designated Series B Preferred Stock Pursuant to Section 151(g) of the General Corporation Law of the State of Delaware