frfrrer-97/Med.

-e
ffiq s{6tt offi'd ilrI vrd cREn d sreff cRqql efr/qr veilErcr gq srd sd d qIyS iEr wqr ovi iFr eTrtfi qr
Form
ofapprication 'J":'lH::T:[wirhMedica,
attendance
:?:,"*'il::?J:11T,
?:ff$"3:,::ffi::: S"Jff:
Eqrr ffFdS :-E{ tt{t d frq gi-f,rriF'l-dq{I qlql sGq//v.e.-separaieformsheuktbeusedforeachFatient"
1 . lc-{frrfrotrqtt s] qFrei}sqE ftns. Greilri
i)
Name and designationof the Governmentservant(i'nblock letters)
2 . fu-s .nrqidq ii orq o-{ {6t t/otri"" inwhichemptoved
J. orqrcf,dqq t ndcsfi fr G qR'qTqr
d qen q-{flt s{qt @ltf,{, qR erq oiq
gq-dFilqrd dr g+ cnf,rrt R-q|qr qlcr qGq/payof theGovernmentservantasdefined
i(the^Fundamental
Rulesand any otheremolumenis
whichshouldbe shownseparately.
4. TffrTI OI telFl/Place of drrty
5 . fuqlg ?FTSIt-Tft-{ lTillActuat residentialaddress
6 . tfr ot ilq Sq fft-orfr ofqt t vq-al qqsr
Nameof patientandhis/herrelationship to theGovernment servant
t4fq frfuS-qR ftqn trqr Ei dI gs-6 sq fi ftTd vrg/ru.g.-in tnecaseofchitdren
stateageatso.
7. R).fr fu-tf TQdFIrlt fiqfS q.gf,/ptaceat whichthe patientfelt;il.
8. Ed +t .{f,-q FI adkl/oetrirr of the amountctaimed.
t. sr€fl cRrqf/MeolcAL ATTENDANcE-
(i) FqF -mo erd\ tnl frtv oG.gl q-qmqf al qTq/rees forconsuttation indicatins-
(o) fufl.frfrffir orm t.cqTqdh'qt^rrqJt, - s-miqr-q3il( q-qcerjs-€ GrskTrFT
ql 3ITqtTIqfqcFI qIrT lGf{RI q-E slpfq;t{t o='- B I
( a ) the.nameand designation of the medicalofficerconsuhed
and the hospitalof dispensary
to
whichattached.
ru) Fad q( {< ft\ frrq fl-fi-s o-)qttqRifuqr rrqref< rt qq-qrfd ftr} ffi
ItD-d;IlSRT EI rrg E I
(D) tlrenumber
anddatesofeunsultations -
andthefeepaidforeachconsultation.
(ri) fu-aftgtql frn-fu-{ d;fui oi d,fr eili ERg-i d frq ffi *fi q1Sr
(c) the numberand dates of-injectionsand the fee paid for each lnjection.
(s) Sl v3ryi ei<7urg-fu ci-sardtt d .r{ qr fufu-esT d qr
sTffi d T{qrf znel
{t-rTI o FItINI {QIFT rrq I
(d) whetherconsultationand/or injectionwhere held at the ho_spital,
at the consultingroom of the
medical officer or at the residence of the patient.
(ii) tFr or ft-<rqo-qdrrrrr fuq Tq ffi-ffi-6, dfqTul-ffif,, frfrt{sr-ilflftT sitq
f€ fr q3rt qteTur.FTqd frfuf,'*i ffifuo ffi enqr5q-
charges.for p.athological,
bacteriological,radiologicalor other similar'testsundertakenduring
diagnosisindicating-
qr i|tlmcTljf,I6-r qrrTwi qfreTqgq, 3ilR
\.n/ €ilsRTrcr
( a ) the nameof the hospital
or laboratory
wherethe testswereundertaken,
and
(rs)rytj l!!"1qrqf--frfu-fl qRsF+ +1q-f,rEqr Eg,qfr Eidr swFl eqM-rH
EH4 qIzI ETfK/(b) whetherthe tests were undertakenon the adviceof the authorised
medicalattendant.lf so, a certificateto thatefbct shouldbe attached.
CI qrqmt qftfr .r{ E-qrGIi
q {e t
(d) costs of medicinespurchasedfrom the market.
(<+reiie1q4, ro<-v* ef{ ea-€'rqero-ar
srrrur-qrflsr arrry)
(List of medicines,cash memos& tDeessentralityceftificatesshouldbe attached)
ll. 3rsfrrs snTq/HosptTAL TREATMENT-
SISkITFI6-l iFllName of the hospitat.
3i-sf,rfr Ff,ru d qd-ffifua qd tnTst?t-q-slFrr
frftr a;lfu\-
Chargesfor Hospitaltreatmentindicatingseparatelythe chargesfor-
(t) 3il-qfs 4l,/Accommodation
({6 ft.dj fu wr eirqrflvwt-fr o-{iqt d qriqrqd-trcqr tfuqil g srysq s1ur
sB afr et Vq sTrcrq eT Vm'ryIur-q;{d fu fuff q-mRd snErfld ftfr qr-fl-ft
o-rl4t-tl6m-<RqTqEsrrFfer€ *),
(Statewhetherit was accordingto the status,or pay of the Govemment sewantand in cases
wherethe accommodation is higherthan the statusof the Governmentservanta certificate
shouldbe aftachedto the effectthat the accomrnodation to which he'was entitledwas not
available).
(ii) $trfiloiet
(iii) Ykqfrqr qr sr€fr {fl\'T qTcR-tts
Surgicaloperationor medicaltreatmentor confinement
fuffr-ffi{-o, $-{tg-ffio,
0/) qlg/Pathological, qI sralcfreTq
trfr'-*sr-n-flA5' q6'{trl fr q-d-cTr{
bacteriological,radiologicalor other similar tests indicating+
(o) erw-amqr rqtrntriil inr qrq fuflfr qtflur gq
(a) the nameof the hospitalor laboratoryat whhh undertaken.
(s)
. g_! ggq.grfq@t@r
qRFIs-I SFIM-qd TIIS TIT( ;
t qrrdra i gq? qR ei drqs
eTffi +t s"dr-6
(b) Whetherundertaken on the adviceof the medicalofficerin chargeof the caseat the hospitat.
lf so, a certificateto that efiectshouldbe attached.
 (v) gqry7ir.6;.;...
(vi) fr*q E4l-(/Speciar
medicines
(<ql't th1dfr qo-E:qr Gil{ cfiiqrqq?rb-drqflur-q-{ rfi mr|-g)
.. (List of medicineS,cashmemosand the essentialityceftificatesshouldbe attached)
(vii) wqnq gqzHf/ordinary nursing
q-6ftrd tu C aN rd
ffl-er i q-dr6ff efrsl
{ r qrd srfr R€{fr+i
n sTRqfr-c{w fufuet
Specialnursingi.e. nurses speciallyengaged for the p:atient, State whetherthey were em-
ployedon the adviceof the medicalofficer-rn-chargs of the case at the hospitil or at the
requestof the Government'servant or patient. In ihe formercase,a certificatefrom the medical
officer-in-chargeof the cdse countersignedby the Medical Superintendentof the hospital
should be bttached.
(ix) vqefq qE-d(o-6rt a-6i Tf, ql-n +t G {6 ftrd)
Ambulancecharges(Statethe journey-toand from underiaking)

ftds-dt q6fifr.dj
fttrq q-6T.riolg fr-q
::;:":
#t;:T:
IiJi_ll
:l:
ftqfbl.+i :- 1. qR arTldqsfl Sqr lqflfr.rrr qRqqf fi-qqrqdl 1938d flqq.glsd 3Glrs'lq ddd] 3rTF
*te.H o,ff*
[w"^ v") sR{, 1938]d 3r1qrTs qr ddq riqr (Afo.cw qR"-qfi ig++ # f+qq z d'rs-a z err6
r( rlTogqo (gqo{o) ser, 1%4ld^gwn uR verq rmmt-fro*iq]fr d ftqrr] {a{Ttq{ €t g.r Ei + sircl
ftqTor t sils qc lffi d er<,fo 3{tffre fqlficn qRqrqo -' q*"r-# q.jLTFilTTqI
Noles :- lf the lreatment was receivedby the Governmentservantat his residenceunder rule 3 of
the secretary of states service (M.A.)
Rules,1938or rule7 of the C S (M.A.)Rules,1944give particulars of suchtreatmentand attach certificate from the authorised
medicalattendantsas requiredby these rules.
2' qR qdM {ff+Tfrsrslclrdd eroror.@ etrq'rqe $rTt d srrot iilr+{q?D t si{ qTgqrd
ft-cri"T ftfu-f,1 qR-4-{o
oTEq 3ilfls al Frq-qa t fu 3rtfhdSfl-q al t+sa{ ft;qfrfirhedq q-qa1tGRffi. fr # d ffi * 1'
lf treatmentwas receivedat a hospitalother than a GovernmentHospitalnecessarydetails
and the certificateof the authorised
medicalattendantthat the requisitetreatmentwas not availablein any nearestGovernment
hospitalshouldbe furnished.
lll. R*qf, t RrqsflcoNSULTATtoN
WrrHspEctAltsr-
b_f,l erlsfrft oT q{.|.qei
;es paidt6 a specialistor a

$ t elxzEfrtrEf,
"*
(a) The nameand designation
of the specialist
or medicalofficerconsultedandthe hospitalto
which attached.
eils e-rq{rqefd ftl-s

fH#T$i"j,i".ku'-
(c) Whetherconsultation was heldat the hospital,at the consulting
room of the specialistor
medicalofficeror at the residenceof the oatient?
(s) q^qTfrtrss el frfrif,fl<Tfffi of s-cTr6
erfhp.-dfrfuffi-qRqrn of vrq1t
dt.rg.tt.l- 1na13^5qwnrwft-o-frffin srffi o1$ {Sg"frilrd
ffi qFil o-{ fr ,r-$.t't r" qR a dr qq+$ftr-qqqpr-G aq,q r
(d) Whetherthe specialistor ntedicalofficerwas consultedon the adviceof the authorised
medicalattendantand the priorapprovalof the ChiefAdministrativeMedicalOfficerof the
state was obtained? rf so, a certificateto that effectsshourdbe attached
9. q-o f}_ofr q=firfu o-I qql -B/rotrlamount
ctaimed $o/Rs
10 ' rlqr qc qdro-VLessadvancetakenon
o) fu{I erfuq so,/Rs
11. EIi 61 qd tml/Net aniountctaimed So/Rs
12. 11ii=-{t|ti O1 qfi71;.1of enctosures-

gg dqqt qr srorff 6Cqt Ewtert oit/oTc ueeIoN To BEStcNEDByTHEGovERNME

NTSERVANT
t thR-<orlefuq- ft* Tqr6qtqnt qqoT-fieifsfrrqTqd er-gvm
eo t eilr fu-siqfu d sc{
i';ift;qn qq fu\ rrv B, q-a'pf6 , tilttr*-* I
u'w silf**a E t "l
I herebydecldrethat the statementsin this applicationare true to the best of my knbwledgeand belief and that
the person or wnom
medicalexpenseswere incurredis wholly dependentupon me.

.
jare H-{oTfr tndett d erfler< ei}< q16 frst qE 6Tq.nt q-6Tt
Signature of the Government servant and office to which attached
qql{{3eold/MGtpTKot-7 civit/2006-07-(c_7)-3_646_7,00,000.
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q-qrq-qeg q6-q6'frfu-ff erffiTvar+o qtgrfrfu-ffi 3Tffi €rq.................................

slcR-flddr
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 te-tol/t*eo.-r
o:
"' -""
""':""" " ":"""""""r""'-"" * t+gw *rft7$7qqrfi """ . "' ' :

Certilisatc granted to Mrs.lMr.lMiss

wif'elsonldaughter of Mr

e m p l o y e di n t h e . . . . . . . . . . . . .. . . ,

: ,
' 'r , (Eqtlffii d' qTTd't tr{Tqrq ftr+ Fdrq d ftg er*++rai .rff c fuuerrurdt}
- (To,becompletedin ths caseof patientswho are not admittedto hospitaltbr treatmbnt)

I,Dr. ,: - ,herebvcertifv:-

(o) fr f erci Trrq{f 6H C/+rf + F-{r{{renqq{ (erfd A qrq} ....'.'..'.':'.'

q l "
(aI t h a t I c h a r g e d a n d r e s e i v e dR s , , _ ,,. , - tbr
consulta{ibns on..- at rny consulting room/at the residence of the patient
(Dates to be given.)

(tEI f ti srri wnd ft itl*?f d F-qfs {eF c{

oJ ett' i$Zsrrrsqq E-$-fnE ti d frq . . . scq c.Tftd
Fa*qor)ycrq ft-q r
(b) administering..- - . .. mtra-muscular/sub-cutaneous
injectionson
.. al my consulting room/at the residence of .the parient
(Ddes to be giveni

(.1) fu frq rrq {dzF.{rqrtqemdrqr *rr frdq d ftq e),/T€tai I

(c) that the inj€clionsadnrinisteredwere/werenot'for immunisingor prophylacticpurposes.

(e) f *.f ?Fr{encr""" """'srsnTi-ftztt e-fqrf oeTd goi * ,si{ {q

tt sm Td { A'T-gft,-rfufutr oltqti*.t el creroeldFfi o--ri/.ifiq w d ssre *i d ++-f d frq erFqrd,fi r i
3isd..'.."-.'.:'...'.'-...'....'..''...'...,.3[-skIIFIr
(3{-SRfrdrFr Trq)
T€ldqrft3ilYE-+*lit-d(\'rts-d)-utrrvnfr*aqfiBffifuqqqnfrRffirqr-rdvrriq-qsqFrartcfitrh'r
d Tfld: srq, TrrNqrzrft sTefdt
ft:dnrqo B t
(d) thar the parienthas beenunderrreatmentat ,hospitat/my
consultingroonr'andthat the undermenfioned medicinesprescribedby me in this connection
wereessentialfor t5e recovery/preventions
ofserious
deteriorationin the conditionof the patient The rnedicinesare not srockedin ihe (nameof the hospital)
fbr the supplyto privatepatientsand do not includeproprietary
preparations
tbr whichcheapersubstances
of equaltherapeutic
valueareavailablenor preparations
whichareprimarilyfoods,toiletsor disint'ectants

c|?t+tct
otqd
F-q lfo ets.E6-rc.rq Pri ce *-f {Io ffio-rclq Price
Sl No Nams of the Medic.ines go Sl No Name of the Mediomes
\)o Fo Qo
Rs P. R s P
I 6

2 , .7

J 8

4 9

5 t0

F-

I?o to $o/P T o.
 (-s) fb R)-ft d fiGn t,zqr eilq " " . ri
.io R gcTia d Br'erTi
(e) thar the patientis/wassutTering
frorr
is/rvasundermytrcatmentfrom . . : : to ., .

(q) fu t-rfro1q=qW s?rfl rrqtw frRtf,{ret qi iZefrI

(l') that rhe paticnt is/was not given prenatal or post-natal treatment

(u) fu ftfi \-qffii, qd.Tarcr ETa 3TrRd fuq "';"" "" """"'.'Fsqsd fuq s) i erqsqq;cl eiE tl
tgFil6t ....."..........'...:.......'..
. ".""" """'.':"':::'-;"""i':Ti:$qrK e)|
(smm-oql ndtwfidr 6r {T+r):: , : .,
(g\thatX-ray,laborator1.teSt.9tct.or,'vhichanexpenditufeolRs...::.'.

was incurred !\'ere neccssal) and ]vere undertaken on my advice at"

1nu*" of ,r," hosprraior raboratory-l

3r5{JT{qe.nqR.d3{kTTq-63Edl--<qsTW?F-{' 2r I
rh ) t h a t I r e l c r r e d t h c p a t r e n tt o l - l r ior speetalisi

c o n s u l t a t r o na n d t h a t t h e n e c e s s a r ya p p r o v a l o f t h e
(name of the Chief Administrative Medical cer)
as required under the ruies was ob{arned

(st) f,o dtft d ersorc i {q+ flsrq-o c-fi Q,Tt,/ QIT

I
(i) thal the pirtientdid not requrre/required
hospitalisation

- , t

-
d,rfig' Afrffir .ffi d,ffirers s*v c++rs'ilen'
DilIC
, €ffi frr .r#rffi qE ereg Sr
'"ry;:"*ffi;^:;:;:!;'rr#:;':,,.,,;"
qT{tqFiI gl
N. B -Certifircatesnot applicableshould be struck off. Certificates to be compulsorv and must be filled in by the r\,leriicalOtTiccr in sll *is,:s

, q+nfiqriq') Fi/lMGit, i-i(oi- i r Crrrii?008-09-iC" i 3 j-t7- 1 1.O*q-S,

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