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Medical Reimbursement Form For Maharashtra Government Employees PDF Free Download
Medical Reimbursement Form For Maharashtra Government Employees
- Name and designation of Government Servant (In Block Letters)……………………………………………………………
(i) Whether married or unmarried …………………………………………
(ii) If married, the place where wife/husband is employed……………………………………….………………………. - Office in which employed
- Pay of the Government servant as defined in the Fundamental Rules and any other emoluments, which should be shown separately. ………………………….
- Place duty. ……………………………………………………………………
- 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. - Place at which the patient fell ill. …………………………………………….
- 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 Pages | 16 |
| PDF Size | 1 MB |
| Category | Form |
| Source/Credits | – |
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Medical Reimbursement Form For Maharashtra Government Employees PDF Free Download