Medical demp

Medical Reimbursement – Data Entry

Employee Name

Designation

Department / Office

Patient Name

Relation of Patient

Relation Tag S/oD/oW/o

Father/Spouse Name

Age

SexMaleFemaleOther

Basic Pay (₹)

Hospital Name

Treatment From

Treatment To

No. of Days Admitted

Diagnosis

Discharge Summary / Notes

Charges Breakdown (₹) — amounts auto-total

OPD Charges

File Charges

Room Charges

Nursing Charges

Doctor Visit

Lab Charges

Medicines/Consumables

Other Charges

Net Amount (auto)

Certificate Points (Page-1)

Illness/Case

Nearest Civil Hospital

MEDICAL RE-IMBURSEMENT CERTIFICATE

1. I certify that , , employed in the , has been under treatment at the / under my consulting room. The medicines prescribed by me in this connection were essential for the patient’s treatment and for recovery / prevention of serious deterioration. These medicines were not available from hospital stock and the items do not include proprietary preparations for which cheaper substitutes of equal therapeutic value are available, nor preparations that are primarily food, toilet articles or disinfectants.

1. Certified that the treatment was necessary.
2. Certified that the medicines are not borne on the list of the medicine store depot.
3. Certified that the medicines charged have no cheaper effective substitute.
4. Period of treatment: to .
5. Certified that the price claimed is reasonable.
6. Certified that the medicines are not in the nature of tonics etc., the cost of which is not reimbursable under Government orders issued from time to time.
7. Certified that the medicines prescribed are not in the list of non-reimbursable medicines (Punjab Govt. Letter No. 17194-5/15831 CH5 18H-5/7796 dated 25-01-1966).

She/He was suffering from:

Sr.	Name of Medicines	Date prescribed / purchased	Amount (₹)
1	As per cash memo attached	Attached	—
2	As per cash memo attached	Attached	—
3	As per hospital final bill	Attached	—
4	As per pharmacy receipt attached	Attached	—
TOTAL			0

Signature (Attendant)
Authorized Medical Attendant

Signature
Employee

NEW PERFORMA FOR MEDICAL REIMBURSEMENT

Detail of Patient and Treatment

1) Patient Name
2) Name of Employee
3) Department Relation of Patient	Relation:
4) Date of Taking Treatment from
5) Age & Sex	,
6) Treatment taken from which Hospital
7) Diagnosis
8) Discharge Summary Number of Day admitted with dates	Attached: Discharge summary & supporting documents

Charges
OPD Charges	₹
File Charges	₹
Room Charges	₹
Nursing Charges	₹
Doctor Visit Charges	₹
Lab Charges	₹
Medicines & other consumables	₹
Other Charges	₹
Cost of Treatment (Net Amount)	₹

Signature of Claimant

Signature of Doctor

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