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+.º´ÉÉ.ºÉä.ªÉÉä/CHSS
FORM 7
+xiɇ®úIÉ
‡´É¦ÉÉMÉ EòÒ +Æ„ÉnùɪÉÒ º´ÉɺlªÉ ºÉä´ÉÉ ªÉÉäVÉxÉÉ
Eäò +ÆiÉMÉÇiÉ +Éè¹É‡vɪÉÉå Eäò ¨ÉÚ±ªÉ EòÒ
|ɇiÉ{ÉÚÌiÉ
EòÒ ¨ÉÉÆMÉ Eò®úxÉä ½äþiÉÖ +É´ÉänùxÉ
Form
of Application for claiming reimbursement of the cost of medicine
under
the Contributory Health Service Scheme of Department of Space
(‡´É„Éä¹É
: |ÉiªÉäEò ®úÉäMÉÒ Eäò ‡±ÉB +±ÉMÉ ¡òɨÉÇ EòÉ |ɪÉÉäMÉ
Eò®åú)
(N.B.Separate
form should be used for each patient)
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1.ºÉ®úEòÉ®úÒ Eò¨ÉÇSÉÉ®úÒ EòÉ
xÉÉ¨É ´É {ÉnùxÉÉ¨É (º{ɹ]õ +IÉ®úÉå ¨Éå )
Name
and designation of Government servant
(in Block letters)
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2. EòɪÉÉÇ±ÉªÉ EòÉ xÉÉ¨É VɽþÉÄ
EòɪÉÇ®úiÉ ½éþ
Name
of the office in which employed
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3. ´Éɺiɇ´ÉEò +É´ÉɺÉÒªÉ
{ÉiÉÉ
Actual
residential address
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4.®úÉäMÉÒ EòÉ xÉÉ¨É +Éè®ú =ºÉEòÉ
Eò¨ÉÇSÉÉ®úÒ ºÉä ºÉƤÉxvÉ ¤ÉSSÉÉå Eäò ¨ÉɨɱÉä ¨Éå
+ɪÉÖ ¦ÉÒ ‡±ÉJÉå
Name
of the patient and his/her
relationship with the Government servant
mention the age in case of
Children
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| 5. ®úÉäMÉÒ
EòÉ VÉx¨É ‡nù´ÉºÉ /
Date
of Birth of Patient
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6. +Æ„ÉnùɪÉÒ º´ÉÉ-ºÉä´ÉÉ
ªÉÉäVÉxÉÉ EòÒ {ÉÆVÉÒ. EòÉbÇ÷ ºÉÆ.
CHSS
Registration Card No.
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7. ‡´É„Éä¹ÉYÉ {É®úɨɄÉÇ/Specialist
consultation
1.‡´É„Éä¹ÉYÉ
EòÉ xÉɨÉ/Name
of the Specialist
2.{É®úɨɄÉÇ EòÒ ºÉÆJªÉÉ ´É ‡nùxÉÉÆEò/The
number and date of consultation |
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8. +º{ÉiÉÉ±É ¨Éå ¦ÉiÉÔ/Hospitalisation
1.={ÉSÉÉ®ú
MÉÞ½þ/+º{ÉiÉɱÉ/‡xÉnùÉxÉ MÉÞ½þ EòÉ xÉɨÉ/
Name
of NursingHome/Hospital/Polyclinic
2.`ö½þ®úxÉä EòÒ +´É‡vÉ/Period of
stay |
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9.¤ÉÉVÉÉ®ú ºÉä JÉ®úÒnùÒ MÉ<Ç
+Éè¹É‡vɪÉÉå EòÉ ¨ÉÚ±ªÉ (®úºÉÒnù ºÉƱÉxÉ)
Cost
of medicines purchased from the market (cash memo enclosed)
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| 10. ¨ÉÉÆMÉ
EòÒ MÉ<Ç vÉxÉ®úÉ„ÉÒ/Amount
claimed |
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ºÉ®úEòÉ®úÒ
Eò¨ÉÇSÉÉ®úÒ uùÉ®úÉ ½þºiÉÉIÉ®ú EòÒ VÉÉxÉä ´ÉɱÉÒ PÉÉä¹ÉhÉÉ
DECLARATION
TO BE SIGNED BY THE GOVERNMENT SERVANT
¨Éè
BiÉnÂùuùÉ®úÉ PÉÉä¹ÉhÉÉ Eò®úiÉÉ/Eò®úiÉÒ ½ÚÄþ ‡Eò +É´ÉänùxÉ
{ÉjÉ ¨Éå ‡nùB MÉB iÉlªÉ ¨Éä®úÒ {ÉÚhÉÇ VÉÉxÉEòÉ®úÒ ´É
‡´É„ÉÉºÉ Eäò +xÉÖºÉÉ®ú ºÉiªÉ ½éþ +Éè®ú ´ªÉ‡Hò,
‡VɺÉEäò ‡±ÉB ‡SɇEòiºÉÉ ´ªÉªÉ ‡EòªÉÉ
MɪÉÉ ½èþ, {ÉÚhÉÇiÉ: ¨ÉÖZÉ {É®ú +ɇ¸ÉiÉ ½èþ *
I
hereby declare that the statements in the application are
true to the best of my knowledge and belief and that the person
for whom medical expenses were incurred is wholly dependant
upon me.
ºÉ®úEòÉ®úÒ
Eò¨ÉÇSÉÉ®úÒ Eäò ½þºiÉÉIÉ®ú ´É EòɪÉÉÇ±ÉªÉ EòÉ xÉɨÉ
Signature
of theGovernment servant
and
office to which attached
‡SɇEòiºÉÉ
EòÉ |ɨÉÉhÉ {ÉjÉ
DOCTOR'S CERTIFICATE
¨Éè b÷É0...........................................................................................
BiÉnÂùuùÉ®úÉ |ɨÉɇhÉiÉ Eò®úiÉÉ
½ÚÄþ,
I,
Dr..............................................................................................................................
hereby certify
(Eò)
*
‡Eò ¨Éé ®úÉäMÉÒ EòÒ ‡SɇEòiºÉÉ Eò®ú
®ú½þÉ lÉÉ +Éè®ú <ºÉ ºÉƤÉÆvÉ ¨Éå ¨ÉéxÉä xÉÖºJÉä ¨Éå ‡xɨxɇ±É‡JÉiÉ
VÉÉä +Éè¹É‡vɪÉÉÄ ¤ÉiÉÉ<Ç lÉÓ, ´Éä ®úÉäMÉÒ EòÒ ½þɱÉiÉ
EòÉä ‡¤ÉMÉc÷xÉä ºÉä ¤ÉSÉÉxÉä Eäò ‡±ÉB +Éè®ú ={ÉSÉÉ®ú
Eäò ‡±ÉB +É´É„ªÉEò lÉÓ *
(a)*
that the patient has been under my treatment and that
the undermentioned medicines prescribed by me in this connection
were essential for the recovery/prevention of serious deterioration
in the condition of the patient.
+lÉ´ÉÉ OR
*
¨ÉéxÉä
®úÉäMÉÒ EòÉä ‡´É„Éä¹ÉYÉ Eäò {ÉÉºÉ {É®úɨɄÉÇ
Eäò ‡±ÉB ¦ÉäVÉÉ lÉÉ +Éè®ú xÉÖºJÉä ¨Éå ‡xɨxɇ±É‡JÉiÉ
+Éè¹É‡vɪÉÉÄ ‡´É„Éä¹ÉYÉ uùÉ®úÉ ¤ÉiÉÉ<Ç MÉ<Ç
lÉÓ*
*
The patient has been referred by me to the Specialist and
the undermentioned medicines have been prescribed by the specialist.
| Gò¨ÉÉÆEò
Sl.No.
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+Éè¹É‡vɪÉÉå EòÉ
xÉɨÉ
Name of the Medicines
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¨ÉÉjÉÉ
Quantity
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¨ÉÚ±ªÉ
Price
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(JÉ) ‡Eò ®úÉäMÉÒ .......................................
®úÉäMÉ ºÉä {ÉÒ‡c÷iÉ ½èþ/lÉÉ +Éè®ú ‡nùxÉÉÆEò.......................
ºÉä.......................... iÉEò ¨ÉÖZɺÉä ‡SɇEòiºÉÉ
{ÉÉ ®ú½þÉ ½èþ/lÉÉ *
(b)
that the patient is/was suffering from..........................................................................................
and is/was under my treatment from..................................
to .......................................
ºlÉÉxÉ/Station
:
‡nùxÉÉÆEò/Date:
|ÉɇvÉEÞòiÉ
‡SɇEòiºÉɇvÉEòÉ®úÒ/‡´É¦ÉÉMÉ Eäò ‡SɇEòiºÉEò
Eäò ½þºiÉÉIÉ®ú
Signature
of the Authorised Medical Officer/
Deparmtnet's Doctor
*
VÉÉä
±ÉÉMÉÚ xÉ ½þÉä, =ºÉä EòÉ]õ nåù
*
Delete whichever is not applicable
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