APPLICATION FOR CLAMING REIMBURSEMENT OF THE COST OF THE MEDICINE UNDER CONTRIBUTORY HEALTH SERVICE SCHEME OF THE DEPARTMENT OF SPACE
(N.B. SEPERATE FORM SHOULD BE USED FOR EACH PATIENT)
1. Name & Designation of the Govt.Servant (in Blaock Letters : R. NARASIMHAN
(Serving / Retired) SO / F, (Retd)
2. Office win Which Employed : DAE / IGCAR
3. Actual residential Address : D - 803, BRIGADE METROPOLIS
White Field Road, Garudacharpalya
Mahadevpura P.O
Bangalore - 560048
4. Name of the patient and his / her relationship with Govt. SUDHA.N
Servant (N.B. In case of children state age also) WIFE
5. C.H.S.S.Regd. Card No. AD 30444-02
6. Specialist Consultation -------------------------------------------
Name of the Specialist Consulted ---------------------------------------------
No. & Date's of Consultation ---------------------------------------------
7. Hospitalisation :--------------------------------------------
Name of the Nursing Home / Hospital / Poly Clinic ------------------------------------------
Period of Stay :-------------------------------------------
8. Cost of the Medicine's purchased from Market --------------------------------------------
(Cash Memo to be attached)
9. Amount Claimed ------------------------------------------------
10. List of enclosures Pharmacy Bills
Declaration to be signed by the Govt. Servant
I hereby dere that the staements made in the this application are true to the best of my knowledge and
that person for whome expenses were incurred is wholly dependent upon me.
Signature of the Govt. Servant ----------------------------------------
Office to which attached DAE / IGCAR / AMD
Doctor's Certificate
-------------------------------------------------------------- herby certify
That the patient has been undermy treatment and that the under mentioned medicine's prescribed
by me in this connection were essential for the recovery / prevention in the condition of the patient.
That the patient has been referred by me to the specialist and the under mentioned medicine's have been prescribed by the Specialist.
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Sl.No. Name of the Medicine's Quantity Price
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1.
2.
3.
4.
5.
6.
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That the patient is / was suffering from -------------------------------------- and is / was
under any treatment from ------------------------------------ to ---------------------------
Place : Signature of the Authorised Medical Officer /
Date : Department Doctor
Delete whichever is not applicable
