Medical Reimbursement Form and Essentiality cum Emergency Certificate - Northern Railways |
Medical Reimbursement Form and Essentiality cum Emergency Certificate – Northern Railways: PDF & Text
REIMBURSEMENT CLAIM FORM
1. Name of the Railway/Retd. employee (In Block Letters) ………………………………..
2. Designation of the Railway /Retd. Employee (In Block Letters)…………………………..
3. Office and Station of employment ………………………………………..
4. Pay/Last Pay of the Railway/Retd. Employee including grade pay………………………..
5. Residential Address…………………………………………..
6. MIC/RELHS No. and issuing Authority …………………………………………..
7. MIC/RELHS registered at H Unit/Hospital…………………………………………..
II (A) Name and age of the patient …………………………………………..
II (B) Patient’s relationship to the Rly/Retd. Employee…………………………………………..
III Detail’s of Indoor Treatment at Non Railway Institute…………………………………………..
A Name of Hospital: …………………………………………..
B Date of Admission: …………………………………………..
C Date of Discharge: …………………………………………..
D Diagnosis : …………………………………………..
E Amount of Total Hospital Bill (Attach detailed bill): …………………………………………..
F Whether Treatment was taken in emergency : …………………………………………..
G Are you a CTSE member (Y/N): …………………………………………..
IV. a) Whether subscribing to any Health insurance Policy or covered under any other health scheme:
b) Whether any advance payment was processed for this claim, if yes details thereof.
(If yes, have you received any amount from insurance company for the treatment in question. Give details if any on separate sheet of paper)
V. Total Amount Claimed:
VI. Details of Bank account where Reimbursement amount is to be paid:
a. Name of Bank
b. Branch MICR Code
c. Account No.
d. IFSC Code.
VII. List of enclosures (Please Tick the documents attached and write additional documents)
A. Photocopy of MIC/RELHS card
B. Essentiality cum Emergency Certificate by the Non Rly Hospital
C. Discharge Summary
D. Original bills of Hospital
E. Original Cash vouchers of Drugs/consumables/implants etc. if relevant
F. Outer pouch of stent, pacemaker, Implants etc.
G. Any other enclosure…………………………………
(In case of many enclosures, write number of additional enclosures here and attach separate sheet with details)
DECLARTATION TO BE SINED BY THE RAILWAY EMPLOYEE
I hereby declare that the statements in this application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me. I am aware that misuses of medical facilitate or misrepresentation of any kind can attract penal action including cancellation of MIC / RELHS Card. I hereby declare that this is my final claim and I shall not make any claim in future to Rly or any other health scheme in respect to this treatment episode.
Date :
Place :
Incharge
Signature of the Railway Employee.
In case the beneficiary has medical insurance policy and intend to make claim for the treatment in question then he/she may make claim to insurance company first and then submit claim to Rly. With documents, bills etc. attested by insurance company.
NORTHERN RAILWAY
MEDICAL DEPARTMENT
ESSENTIALITY cum EMERGENCY CERTIFICATE
I certify that Shri/Shimati/Kumara/Kumari _______________________________ wife /son/ daughter / dependent _______________________________ relative of Shri / Shirmati _______________________________ , employed in Indian Railway as , has been under my treatment for _______________________________ disease from ______________ to _________________ at the _________________ _________________ hospital and that the treatment as described in the attached Discharge Card No. _________________ and attached bills thereon were provided due to an emergency situation, treatment for which could not have been delayed. I further certify that the treatment provided was essentially required.
Signature of the Medical Officer
In charge of the case at the non-Railway hospital
With Name and Stamp/Seal
Signature of Hospital In-charge or
Authorized signatory with Stamp/Seal
PART ‘C’
I hereby certify that Sh./Kumari _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ wife /son daughter _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Employed in the _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ has been under treatment for _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ at the _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ hospital and that the facilities’ provide were the minimum which were essential for the patient’s treatment.
Date:-
Place:-
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ hospital
ANNEXURE ‘C’
NORTHERN RAILWAY
To establish the emergency condition following parameters are to be examined on:-
Admission details:
(i) Date and Time of Admission :
(ii) Admitted through OPD service/ :
Emergency service
(iii) Admitted to an ICU bed/general Bed or cabin bed :
Clinical finding at the time of admission:
Following findings should be made available & critically evaluated
(a) Pulse rate :
(b) B.P :
(c) Level of consciousness :
(d) Any convulsive feature :
(e) Urine Output :
(f) Any other feature of stock :
(g) Body temperature :
(h) Extent of external wound :
(i) Extent of active bleeding :
(j) Extent of Chest of pain of pain
In other part/s of the body :
Type of medical treatment given immediately after admission:
(a) List of Emergency medicines used
Immediately after admission
(b) Type of surgical procedure done
Immediately after admission
Signature of the treating Doctor
सà¤ी बिलों की मद/तारीखनुसार सारांश
DETAIL OF DATE WISE/ITEM WISE BREAK UP OF ALL THE BILLS OF
(रोगी का नाम/Name of patient…………………………………………………………………………….)
| क्र.सं. Sr. No. | दिनांक Date | बिल संख्या Bill No. | दवा विके्रता/ फर्म का नाम Name of Chemist/ Firm | मद का विवरण Description of Item | मात्रा Quantity | कीमत Price |
प्राधिकृत चिकित्साधिकारी के हस्ताक्षर
Signature of Authorised Medical Office
चिकित्साधिकारी/अस्पताल के इंचार्ज के हस्ताक्षर
Signature of the Medical Office/Incharge
The case of the Hospital
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