This document is an application form for reimbursement of medical charges incurred by a serving or retired government servant or their dependents. It requests information such as the name and designation of the government servant, patient name and relationship, diagnosis, and treatment details including medicines, hospital bills, and tests. The form requires certificates from the medical attendant confirming the necessity of treatment and that substitutes were not available from government facilities. It also requires declarations from the government servant regarding dependency and consent to recover any overpayments. Approval signatures are needed from departmental and hospital authorities.
This document is an application form for reimbursement of medical charges incurred by a serving or retired government servant or their dependents. It requests information such as the name and designation of the government servant, patient name and relationship, diagnosis, and treatment details including medicines, hospital bills, and tests. The form requires certificates from the medical attendant confirming the necessity of treatment and that substitutes were not available from government facilities. It also requires declarations from the government servant regarding dependency and consent to recover any overpayments. Approval signatures are needed from departmental and hospital authorities.
This document is an application form for reimbursement of medical charges incurred by a serving or retired government servant or their dependents. It requests information such as the name and designation of the government servant, patient name and relationship, diagnosis, and treatment details including medicines, hospital bills, and tests. The form requires certificates from the medical attendant confirming the necessity of treatment and that substitutes were not available from government facilities. It also requires declarations from the government servant regarding dependency and consent to recover any overpayments. Approval signatures are needed from departmental and hospital authorities.
This document is an application form for reimbursement of medical charges incurred by a serving or retired government servant or their dependents. It requests information such as the name and designation of the government servant, patient name and relationship, diagnosis, and treatment details including medicines, hospital bills, and tests. The form requires certificates from the medical attendant confirming the necessity of treatment and that substitutes were not available from government facilities. It also requires declarations from the government servant regarding dependency and consent to recover any overpayments. Approval signatures are needed from departmental and hospital authorities.
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Sr
Name of the chemist Shop/
Name S & Date of Name of Drugs/ Medicines/ Amount Hospital/ Clinic/ Quantity Bill/ . Cash Memo Detail of tests. Rs. Dispensary #
Signature: _______________________
Full name of Government servant:
APPLICATION FORM FOR REIMBURSEMENT OF MEDICAL CHARGES IN RESPECT OF SERVING/ RETIRED GOVERNMENT SERVANT AND HIS/ HER DEPENDANTS PART-A 1. Name, Designation, BPS of the serving/ retired Federal Government servant, (Alive/ Deceased): ____________________________________________ 2. Name of the patient and relationship with the claimant as dependent, as specified in rule 2 (d) of the Federal Service Medical Attendance Rules, 1990: __________ 3. Diagnosis of the patient: _______________________ 4. Ministry /Division /Department/Office of the serving/ retired Government servant at S.No.1 O/ o the Director General Accounts Works Lahore. 5. Vendor No.: ________________PPO No. for retired: ___________________________ 6. List of medicine with quantity /hospital bill/laboratory and other diagnostic charges etc. for which reimbursement is claimed through this bill (format attached).
Part-B Certificates by Government Servant (or member of his family in case of deceased Government Servant). Certified that: i. The member (s) of my family for whose treatment reimbursement has been claimed is wholly dependent upon me. ii. The claim was not drawn before. iii. I shall have no objection to the recovery of any amount overpaid, if any, from my pay/pension or otherwise.
Signature: _________________________
FULL NAME OF THE GOVERNMENT SERVANT
or (claimant family member in case deceased) _________________________ (IN BLOCK LETTERS) Date: ___________________
CERTIFICATES BY THE AUTHORIZED MEDICAL ATTENDANT
Certified that the medicines/ drugs/ hospitalization/ clinical test/ examinations listed below were essential for the recovery and restoration of the patient, ___________________ 2. It is further certified that neither the medicine/drugs etc. nor their effective substitutes could be supplied from the hospital / dispensary. Signature: _________________ Designation: _________________ Date: Official Stamp: _________________
