vfrfjDr e.Myh; fpfdRlky;
Extra Divisional Hospital
vuqla/kku vfHkdYi ,ao ekud laxBu] y[kuÅ
Research Design & Standard Organisation, Lucknow
izfriwfrZ nkok QkeZ ds fy;s pSd fyLV
CHECK LIST FOR RE-IMBURSEMENT FORM
1-
fpfdRlk@ vkj-bZ-,y-,p-,p-@igpku&i= dh jktif=r vf/kdkjh }kjk lR;kfir izfrfyfiA
Medical card/ RELHS medical card photocopy duly attested by gazetted officer.
2-
(A) jsQMZ fLyi
Referred Slip
(B) ftu dslksa dks jsQj ugha fd;k x;k gks] deZpkjh@lsokfuo`Ùk deZpkjh dk izkFkZuk&i= ftlesa ejht dks vLirky esa HkrhZ djus ds le;
ejht dh gkyr@mu gkykrksa dk mYys[k djsa ftlds dkj.k uku&jsyos vLirky esa bykt djok;k x;k gSA
For non-referred cases Application of employee describing the condition of the patient and circumstances for going
directly to non-railway hospital.
3-
fMLpktZ fLyi dk ewy izek.k&i=@iphZ
Discharge slip in original
4-
fcy@okmpj dh ewy izfr;ka
bykt djus okys MkDVj }kjk gLrk{kfjr@izkf/kd`r fpfdRlk vf/kdkjh }kjk gLrk{kfjr
Bill/Vouchers (In original and one photocopy)
(Duly countersigned by treating Doctor)
5-
lHkh fcyksa dh lejh Øeo rkjh[kuqlkj tSlk fd izfriwfrZ nkok QkeZ vkSj tks bykt djus okys MkDVj }kjk gLrk{kfjr@izkf/kd`r fpfdRlk
vf/kdkjh }kjk gLrk{kfjrA
Summary of bills in serial number/date wise as given in reimbursement claim form and (duly countersigned by treating
Doctor and countersigned by AMO).
6-
bykt djus okys vLirky ds MkDVj }kjk tkjh vko”;drk izek.k&i= tks fd vLirky ds fpfdRlk v/kh{kd ;k bUpktZ }kjk izfrgLrk{kfjrA
Essential certificate (signed by treating Doctor and countersigned by Medical Supdt./incharge of the hospital.
7-
fpfdRlk izfriwfrZ QkeZ deZpkjh ,ao fu;a=.k vf/kdkjh@;wfuV izHkkjh }kjk izfr gLrk{kfjrA
Medical reimbursement form duly signed by employee and controlling officer.
pSd fd;k ,ao lgh ik;k
Checked and found O. K.
-------------------------------------------------------------------------fpfdRlk foHkkx ds O;kokgkfjd fyfid ds gLrk{kj
Sign. Of Dealing Clerk of Medical Deptt.
iathdj.k la[;k
------------------------------------------------
Registration No.
fnukad ---------------------------------Date
uksV%& mijksDr vuqyaXudksa ds fcuk QkeZ Lohdkj ugha fd;s tk;saxsA
Note:- Without above enclosures form will not be accepted.
1
lsok es]a
eq[; fpfdRlk vf/kdkjh]
vkj- Mh- ,l- vks- fpfdRlky;]
y[kuÅA
fo’k;%& fpfdRlk izfriwfrZ nkok ds lEcU/k esAa
egksn;]
lfou; fuosnu gS fd izkFkhZ@izkfFkZuh us viuh iRuh@ifr@iq=@iq=h@vkfJr@Lo;a ------------------------------------------------------------------------------- ds bykt ds fy, e.My fpfdYlky; m0js0 y[kuÅ ds i= la0 --------------------------------------------------------------------------- fnukad ------------------------------------------------------- }kjk -------------------------------------------------------------------------------------- dks jsQj fd;k x;k Fkk@ fjQj ugha fd;k x;k Fkk] fdarq ------------------------------------------------------------------- mipkj gqvkA mipkj ds nkSjku dqy : ------------------------------------------------ [kpZ gqvkA
eSa ?kks’k.kk djrk gwa fd bl fpfdRlh; mipkj esa O;; /kujkf”k ds fo:) esjs }kjk esfMDyse@fdlh
vU; L=ksr esa Dyse ugha fd;k x;k gS rFkk uk gh fd;k tk,xkA eSaus jsyos ls bl jksx ds mipkj ds fy,
dksbZ Hkh fpfdRlk vfxze ugha fy;k gSA
vr% Jheku ls fuonsu gS fd izkFkhZ@izkfFkZuh dks mipkj ds nkSjku gq, dqy [kpZ : ----------------------------------------------------------- fnyokus dh d`ik djsAa
esjk fooj.k fuEu izdkj ls gS&
¼ izkFkhZ@izkfFkZuh ds gLrk{kj½
Ukke ------------------------------------------------------------------------------------inuke -------------------------------------------------------------------------------ih,Q ua0@ ih- ih- vks- ua0 ---------------------------------------is xzqi@fcy ;wfuV ua0 -------------------------------------------------eksckby ua0 ----------------------------------------------------------------------cSad dk uke ---------------------------------------------------------------------cSad [kkrk la0 -----------------------------------------------------------------vkbZ,Q,llh@vkjVhth,l dksM ------------------------------,evkbZlhvkj dksM ----------------------------------------------------------
2
vfrfjDr e.Myh; fpfdRlky;
Extra Divisional Hospital
vuqla/kku vfHkdYi ,ao ekud laxBu] y[kuÅ
Research Design & Standard Organisation, Lucknow
fpfdRlk izfriwfrZ & QkeZ
MEDICAL RE-IMBURSEMENT FORM
1-
deZpkjh@HkwriwoZ deZpkjh dk uke
%
Name of Employee/Ex. Employee(In Block Letters)
2-
deZpkjh lsokjr@lsokfuo`Ùk gS
%
Whether serving or retired
3-
inuke
%
Designation
4-
fdl dk;kZy;@;wfuV esa rSukr gS
%
Office/Unit of posting
5-
deZpkjh dk osru nj ,ao osureku vxj deZpkjh lsokfuo`r gS rks
mldh vafre osru nj
%
Pay & Scale of Employee/Pay last drawn in case of employee
6-
jksxh dk uke
%
Name of Patient
7-
ftl jksxh ds fy;s izfriwfrZ dk nkok fd;k x;k gS] mldk jsy deZpkjh
ls lEcU/k
%
Relationship with railway employee for whom reimbursement
is claimed
8-
jksxh dh vk;q
%
Age of Patient
9-
fpfdRlk@lsok&fuo`Ùk deZ0 mnk0 LFkk0 ;kstuk igpku i= la[;k
%
Medical/RELHS I/Card No.
10- jksxh dks jsQj fd;k x;k vFkok ugha
%
Whether referred or non - referred
11- vxj jksxh dks jsQj fd;k rks fdlds }kjk
%
If referred by whom?
12- ftl vLirky esa mipkj fd;k x;k mldk uke
%
Name of the institution where treatment is taken
13- vLirky esa HkrhZ gksus dh rkjh[k
%
Date of admission
14- vLirky ls NqV~Vh feyus dh rkjh[k
%
Date of discharge
15- izfriwfrZ ds fy;s nkok izLrqr djus dh rkjh[k
%
Date of submission of claim
16- ;fn izfriwfrZ ds fy;s fn;k x;k nkok N% ekg ls vf/kd foyEc ls fd;k
x;k gks rks nsj ls izLrqr djus dk dkj.k
%
Reasons for delayed, submission of claim, if delayed for
more than 6 months.
17- vUrjax jksxh ds :i esa HkrhZ djus dh dqy vof/k
%
Total period of stay as Indoor Patient
3
18- vf/kd le; rd HkrhZ jgus dk dkj.k&;fn 48 ?k.Vksa ls vf/kd le;
rd HkrhZ jgk gks
%
Reasons for long stay (if stayed for more than 48 hrs.)
19- vkikrdkyhu fpfdRlk dk fooj.k
%
Type of medical emergency
20- D;k mipkj ds fy;s jsyos ljdkjh lqfo/kk miyC/k ugha Fkh \
Was there no Railway/Govt./facility available to deal it?
21- fuokl LFkku ls fudVre ljdkjh vLirky dh nwjh ,ao D;k ogka
mipkj dh lqfo/kk miyC/k gS \
%
Distance of the nearest Govt. Hospital & whether facilities
available there.
22- fuokl LFkku ls fudVre jsyos vLirky dh nwjh rFkk D;k ogka miyC/k %
mipkj dh lqfo/kk jsyos vLirky gS] ;fn ugha rks ftl jsyos vLirky esa
lqfo/kk miyC/k gS dh nwjhA
Distance of the nearest Rly. Hospital & whether facilities
available there. If not, how far is the Railway Hospital with the
facilities available.
23- fuokl LFkku@ chekjh LFkku ls izkbosV vLirky dh lqfo/kk gS rks
mldh nwjh
%
Distance of the Private Hospital from residence/Place of
illness, where facilities availed.
24- vLirky ls HkrhZ gksus dh lwpuk jsy fpfdRlk vf/kdkjh dks dc nh
xbZ \
%
When the Railway Medical Officer was informes about such
admission?
25- D;k jksxh }kjk chekjh ls igys ;k ckn esa fdlh izdkj dk mipkj
fy;k];fn gka] rks dc \
%
Did the patient take any treatment before or after for the present
sickness and if yes, when ?
26- izfriwfrZ ds fy;s fd;s x;s nkos dh dqy jkf’k [kjhnh xbZ] nokvksa ds
vyx&vyx [kpksaZ lfgr uhps fn;s x;s QqV uksV dh en la0 ¼p½ dh
foLr`r fgnk;rkssa vuqlkjA
%
Total amount claimed (with break-up of charges) (detailed
instructions at (f) of foot note below)
27- layXudksa dh dqy la[;k
Total number of enclosures
28- deZpkjh ds ?kj dk irk
Employee’s residential address
29- chekj iM+us dk LFkku o irk
Place/Address of falling sick
30- Qksu uaPhone No.
----------------------------------------------------------------------------------------------------fu;a=.k vf/kdkjh ;wfuV izHkkjh ds izfr gLrk{kj
dsoy lsokjr deZpkfj;ksa ds ekeysa esa
----------------------------------------------------------deZpkjh@lsok fuo`Ùk deZpkjh
ifr@iRuh ds gLrk{kj
Countre sign of Controlling Officer/Unit Incharge
(in case of serving employees only)
Signature of Employee/
Ex-Employees/Spouse
4
fpfdRlk izfriwfrZ ds fy;s nkok djus okys deZpkjh fpfdRlk izfriwfrZ ds ?kks"k.kk i= ij gLrk{kj djsa A
Declaration to be signed by the person claiming Medical Reimbursement.
eSa] ,rn~ }kjk ?kks"k.kk djrk@djrh gw¡ fd bl vkosnu esa nh x;h ?kks"k.kk,a esjh tkudkjh ,ao fo’okl ds vuqlkj lR; gSa vkSj %&
I hereby declare that the statement in the application are true to the best of my knowledge and belief and
(1) fd ftl O;fDr ds fy;s fpfdRlk O;; fd;k x;k Fkk og eq> ij iw.kZ :Ik ls vkfJr gSA
That the person for whom medical expenses were incurred is wholly dependent upon me.
(2) fpfdRlk O;; Lo;a ij fd;k x;kA
The medical expenses were incurred for self.
mi;qZDr 1 ,ao 2 esa ls tks ykxw u gks mls dkV fn;k tk;A
(Strike-out what is not applicable from (i) & (ii) above)
fnukad %
jsy deZpkjh ds gLrk{kj
Date:
Signature of Rly. Servant/
LFkku %
inuke ,ao dk;kZy;
Place:
Desigantion and office to
which attached
QqV uksV@ Foot-note
1-
en la- 18] 19] 20] 21] 22] 23] 24 ,ao 25 dsoy mUgha ekeyksa ij ykxw gksrh gS ftUgsa jsQj ugha fd;k x;k gSA
Item No. 18, 19, 20, 21, 22, 23, 24 & 25 are applicable only for non-referred cases.
2-
bl izksQkekZ ds lkFk fuEufyf[kr nLrkost layXu fd, tk,a%&
Following documents should be attached with this proforma:(i)
deZpkjh@ lsokfuo`Ùk deZpkjh mu ifjLFkfr;ksa dk mYys[k djrs gq, vkosnu djsa ftuds rgr bykt djok;k gksaA
Employees/Retired Employees application giving circumstances under which he/she took treatment.
(ii)
fpfdRlk@vkj-bZ-,y-,p-,l- igpku&i= dh jktif=r vf/kdkjh }kjk fof/kor~ izekf.kr gks & QksVksizfrA
Photo copy of Medical/RELHS I.D. Card (Duly attested by a Gazetted Officer.)
(iii)
mipkj djus okys vf/kdkjh }kjk tkjh ewy fpfdRlk izek.k ftls vLirky ds fpfdRlk funs”kd }kjk izfrgLrk{kj fd;k x;k gksA
Essentially certificate issued by the treating doctor of hospital countersigned by Medical Supdt. of the treating
hospital.
(iv)
vLirky NksM+us dk ewy izek.k&i=@iphZA
Discharge certificate/slip in original.
(v)
mipkj djus okys vf/kdkjh }kjk fof/kor~ izfr gLrk{kfjr fcy@ okmplZA
Bills/vouchers (in original) duly countersigned by treating officer (Authorised M.O.)
(vi)
lHkh fcyksa dk QqVdj fooj.k&bldk rkRi;Z gksxk fd mi;qDZ r en ¼³½ izLrqr fd, x, lHkh fcy@okmpj mfpr <ax ls izLrqr fd,
x, gSaA uhps n”kkZ;h xbZ rkfydk ds vuqlkj %&
Detailed item-wise break-up of all bills (this means all bills/vouchers submitted at (v) above should be reproduced
in Legible Manner As per table shown below:-
Ø- la-
fnukad
S. N.
Date
fcy
la[;k
nok foØsrk@QeZ dk uke
Ekn dk fooj.k
Ek+k=k
Name of Chemist/Firm
Description of item
Quantity
Bill No.
1234-
5
dher/Price
vadks esa
“kCnksa esa
(In Figure)
(In Word)
(vii)
jsQj fd, x, ekeyksa esa jsQj fLyi dh ewy izfr layXu djsAa
In cases of referred cases attach original referred slip.
(viii)
dsl izLrqr djus ds fy, fgnk;rsa %&
Instruction for submission:-
jsQj fd, x, ekeyksa esa vkosnu dk fu;a=.k vf/kdkjh@v/khuLFk izHkkjh }kjk fof/kor~ izfrgLrk{kj djkdj jsQj fd;s x, vLirky ls
fpfdRlk foHkkx esa tek djk;sAa
In referred cases, the application duly countersigned by Controlling Officer/Subordinate Incharge should be
submitted to the Medical Establishment from where he/she was referred.
jsQj u fd, x, ekeyksa esa vkosnu dks fu;a=.k vf/kdkjh@ v/khuLFk izHkkjh }kjk fof/kor~ izfrgLrk{kj djkdj lacaf/kr dkfeZd “kk[kk]
fpfdRlk izfriwfrZ ekeys dks fuiVkus gsrq LFkkfir dh xbZ lSy esa tek djk;sAa
In un-referred cases, the application duly countersigned by Controlling Officer/Subordinate Incharge should be
submitted to the ‘P’ Branch concerned/ to the cell set-up for the purpose of handling Medical Reimburesement.
¼dsoy dk;kZy; iz;ksx gsrq½
(For Official Use Only)
(i)
jsyos cksMZ dks Hksts tkus okys lHkh ekeyksa esAa
For all cases being sent to Board.
(ii)
fcuk jsQj fd;s gq,@v”kkldh; vekU;rk izkIr ekeyksa ds fy, vij egkizcU/kd dh Lohd`fr gsrAq
For AGM’s sanction for unreferred/Non Govt. unrecongnised cases.
1-
eq- fp- vf/k- ds “kCn”k% fopkj
Verbatim view of C. M. OD.
2-
dk;Zdkjh funs”kd ds “kCn”k% fopkj
Verbatim view of ED/Finance
3-
eq- fp- vf/k- ds gLrk{kj
Signature of C. M. O.
6
{ANNEXURE ‘A’}
I certify that the patient had been under treatment of the hospital
………………………………. and that the services of the special nurses, for which
an expenditure of Rs………………… was incurred vide bills and receipt attached,
were essential for the recovery/prevention of serious of the condition of the patient.
Dated:
Signature of the
Medical I/C of the Case
at the Hospital
{ANNEXURE ‘B’}
I
certify
that
Shri/Smt/Km
…………………………………………
Wife/Son/Daughter Shri/Smt ……………………….……… Employee in the
………….…..…………...... has been under treatment for …………….………
Disease from ……………………… to …………………………… at the hospital
………………………………… and that the facilities provided were at the
minimum, were essential for the patients treatment/ recovery.
Dated:
Medical Superintendent
Of the Hospital
7
lHkh fcyksa dh en@rkjh[kuqlkj lkjka”k
DETAIL OF DATE WISE/ITEM WISE BREAK UP OF ALL THE BILLS OF
(jksxh dk uke@Name of Patient ..………………………………………………………..)
Ø- la-
fnukad
S. N.
Date
fcy
la[;k
nok foØsrk@QeZ dk uke
Ekn dk fooj.k
Ek+k=k
Name of Chemist/Firm
Description of item
Quantity
Bill No.
………………………………………..
dher/Price
vadks esa
“kCnksa esa
(In Figure)
(In Word)
…………………………..……………………………………..
Izkf/kd`r fpfdRlkf/kdkjh ds gLrk{kj
fpfdRlkf/kdkjh@ vLirky ds baPkktZ ds gLrk{kj
Signature of Authorised Medical Officer
Signature of the Medical Officer/ Incharge of the
case of the Hospital
8
EMERGENCY CONDITION TO BE CERTIFIED FOR TREATING
DOCOTOR OF NON RAILWAY INSTITUION
(Must be filled up completely and properly)
In order to establish the emergency condition following parameters are be examined on
record –
(a) Admission details –
(i)
Date and time of admission
(ii)
Admitted through OPD service/emergency service.
(iii) Admitted to an ICU bed or general bed or cabin bed.
(b) Clinical findings at the time of admission, following finding should be made available
and critically evaluated –
(i)
Pulse rate
(ii)
B. P.
(iii) Level of consciousness
(iv) Any convulsive feature
(v)
Urine out put
(vi) Any other feature of shock
(vii) Body temperature
(viii) Extant of external wound
(ix)
Extant of active bleeding
(x)
Extant of Chest pain or in other/s to the body.
(c) Type of Medical treatment given immediately after admission
(i)
List of Emergency medicines used immediately after admission.
(ii)
Type of surgical procedure done immediately after admission.
Sig & Seal of I/C of Institution
Sig & Seal of Treating Doctor
9
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