Medical Form, Outdoor Certificate - A

Certificate granted to Mr/Mrs/Miss _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ wife/son/daughter of
Mr. __ _ _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _ employed in the ----------------------------------------------------------------.

CERTIFICATE 'A'
(To be completed in the case of patients who are not admitted to hospital for treatment)
I, Dr. ________________________ hereby certified-
(a) that I charged and received Rs. __________ for consultations on ___________________(dates to given) at my
consulting room/at the residence of the patient
(b) administering _______________________________intra muscular subcutaneous injections on
_____________________________________(dates to be given) at my consulting room/at the residence of the patient.
(c) that the injections administered were not for immunizing or prophylactic purposes
(d) that the patient has been under treatment at ___________ ____ ____ ___ _ _ _ hospital/ my consulting room
and that the under mention medicines prescribed by me in this connection were essential for the
recovery/preventions of serious deterioration in the condition of the patient. The medicines are not stocked in
the _________________________________ (name of the hospital) . For the supply to private patients and do
not include proprietary preparations for which cheaper substances of equal therapeutic value are available no
preparations which are primarily foods, toilets or disinfectants.
Sl.No Name of Medicines Price S.No. Name of Medicines Price
Rs. Paise Rs. Paise
1 9
2 10
3 11
4 12
5 13
6 14
7 15
8 16
(e) that the patient/was suffering from ___ __ ______ __ ______ ____ is/was under my treatment from
_____________to ______________
(f) that the patient is/was not given prenatal or post-natal treatment.
(g) that the X-ray, laboratory test, etc. for which an expenditure of Rs. _ _ _ _ _ _ _ _ _was incurred were necessary
and were undertaken on my advice at _________________.
(h) that I referred the patient to Dr._______ _________________ for specialist consultation and that the necessary
approval of the (name of the Chief Administrative Medical Officer)__ ___ __ ___ __ ___ ____ _ __ _
_________ ____ ____ as required under the rules was obtained.
(i) that the patient did not require/required hospitalization.
Date .. Signature & Designation of the

Medical Officer & the Hospital/Dispensary to which attached.
Note: Certificates not applicable should be struck off CERTIFICATE (A) is compulsory and must be filled in by the Medical Officer in all cases.
FORM OF APPLICATION CLAIMING REFUND OF MEDICAL CHARGES
INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE OF THE CENTRAL
GOVERNMENT SERVANTS AND THEIR FAMILIES.
Note : Separate Form should be used for each patient.
1. Name and designation of Govt. servant (in Block Letters) ______________________________________

2. Office in which employed
--------------------------------------------------------
3. Pay of the Govt. servant as defined in the FR and other
Emoluments which should be shown separately ______________________________________
4. Actual Residential Address ______________________________________
______________________________________
5. Palace of Duty ______________________________________
6. Name of the patient and his/her relationship with Govt.
Servant (in case of children age should be written) ______________________________________
7. Place at which the patient fell ill ______________________________________
______________________________________
8. Medicines purchased from the market (list of medicines,
Cash memos and essentiality certificate should be attached ______________________________________
9. Total amount claim Rs.___________________________________
10. Less advance taken Rs.___________________________________
11. Net amount claimed Rs.___________________________________
12. List of enclosures 1. Essentiality Certificate
2. Cash memos for Rs.______
3. Prescription Slip in original
DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statement in the application is true to the best of my knowledge and belief and that person for
shom medical expenses were incurred is dependent upon me.
Signature of Govt. servant

Office to which attached :
Section :

Medical Form, Outdoor Certificate - A

Uploaded by

Copyright:

Available Formats

Medical Form, Outdoor Certificate - A

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Medical Form, Outdoor Certificate - A

Uploaded by

Copyright:

Available Formats

Certificate granted to Mr/Mrs/Miss _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ wife/son/daughter of

Mr. __ _ _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _ employed in the ----------------------------------------------------------------.

I, Dr. ________________________ hereby certified-

Date .. Signature & Designation of the

Note : Separate Form should be used for each patient.

1. Name and designation of Govt. servant (in Block Letters) ______________________________________

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

Signature of Govt. servant

You might also like