Medical Reimbursement Form For Maharashtra Government Employees PDF

‘Medical Reimbursement Form For Maharashtra Government Employees’ PDF Quick download link is given at the bottom of this article. You can see the PDF demo, size of the PDF, page numbers, and direct download Free PDF of ‘Medical Reimbursement Form For Maharashtra Government Employees’ using the download button.

Medical Reimbursement Form For Maharashtra Government Employees PDF Free Download

Medical Reimbursement Form For Maharashtra Government Employees

  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. …………………………………………………..
  6. 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 consultations and the fee paid for each consultation…………………………………………..

(c) the number and dates of injection and the fee paid for each injection……………………………………………………

(d) whether consultation and/or injection were had at the hospital, at the consulting room of the medical officer, or at the residence of the patient……………………………………

(a) the name of the hospital or laboratory where undertaken; and

(b) whether the tests were undertaken 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)

Language English
No. of Pages16
PDF Size1 MB
CategoryForm
Source/Credits

Related PDFs

EPF Return Form 11 (Self Declaration Form) PDF

Ayushman Bharat Application Form PDF In Hindi

PMFBY Opt-out Application Form PDF

EPF Return Form 3A PDF

Life Certificate Form PDF

EPF Return Form 6A PDF

Medical Reimbursement Form For Maharashtra Government Employees PDF Free Download

Leave a Comment

Your email address will not be published. Required fields are marked *