Medical Reimbursement File Auto Filled.

Page 1: Forwarding

Office of:

To:

District:

Subject:

Content: Respected Sir, With regards, it is submitted that the medical reimbursement case of Rajesh Kumar Sharma, TGT (Mathematics) working in this office is put forward to you for your kind permission and sanctioning of the budget regarding it. Thanking you

D.A.
1. One copy with signed bills
2. One copy with photo copied bills

Head of Institute


With Seal

Page 2: Essentiality Certificate (Part 1)

Name of Claimant:

Designation:

Department:

Pay + Allowances:

Period of Treatment:

District:

Outdoor No:

Date:

Indoor No:

Date From-To:

Patient Details: I certify that Mr/Mrs Rajesh Kumar Sharma wife/son/daughter/mother/father of Mr. Mukesh Kumar Sharma employed in the Government Senior Secondary School, Sector 15, Chandigarh, District Chandigarh, has been under my treatment in the GMCH-32 Hospital in my consultation and that the under mentioned medicines prescribed by me were absolutely essential in the condition of the patient, the medicines were not stocked in the GMCH-32 hospital (Name of Hospital/ dispensary) for supply to the patient and do not include preparations for which cheaper substitute of equal therapeutic value are available nor the preparation prescribed are primarily food/toilets or disinfectants. Certified that 1. The medicines have no cheaper and effective substitute. 2. The treatment was given indoor/outdoor. 3. The price claimed is reasonable. 4. The medicines are not in the nature of tonic or food or vitamins etc. cost of which is not reimbursable in Govt.order issued on this subject from time to time. 5. The patient was suffering from Hypertension and Diabetes (disease)

Disease:

Page 3: Essentiality Certificate (Part 2) - Medicine Details

Medicine Details:

Sr.No.	Name and Quantity of Medicines in capital letters	Outdoor Ticket No.& Price	Date on which Prescribed	Date on which Purchased	Price( Rs.)	Action
1
2

Sign & Stamp of the AMA


(Name in Capital Letters)
DR. AMIT KUMAR SINGH

In case of indoor treatment Certified that the medicine claimed in this bill
are as per ticket no. 12345-12346 & relates to the case.

Sign and Stamp of the AMA

Patient Certification:

Certified that: 1) The medicines have actually been purchased by me during the course of treatment. 2) I am living in House No. 245, Sector 15, Chandigarh, District Chandigarh. 3) I have purchased the medicines from the prescribed co-op store. 4) The medicines have been purchased from private shop after non availability certificate from co-op store/super bazaar. 5) The amount of the medicines purchased from private shop against one or more prescriptions does not exceed Rs. 50/- in a single day. 6) In case of wife/children: That the patient is my dependent and wholly dependent upon me. 7) For parents only: That the patient is my parent and his/her total monthly income does not exceed Rs. 3500/- per month and is residing with me. 8) In case spouse is working: Certified that my spouse is not getting any medical allowance from any source.

Page 4: Performa for Sanctioning of Expenditure

1	Name of Claimant Employee
2	Designation
3	Date of regularization in to service
4	Basic Pay (Pay band +grade pay) as on
5	Present Place of Posting
6	Whether Indoor Patient or Outdoor Patient	Indoor Patient Outdoor Patient Both
7	Period of Treatment
8	Whether Claim is within prescribed time limit (within one year)	Yes No
9	Name of the Hospital
10	Whether the Hospital is (a) Government Hospital (b) Approved Hospital (c) Unapproved Hospital	(a) Government Hospital (b) Approved Hospital (c) Unapproved Hospital
11	In case the treatment is taken from an unapproved hospital, attach the original Certificate of treatment in emergency issued by the concerned Civil Surgeon (if unapproved hospital)	Yes No
12	Whether the Claim relates to the dependent, Give the following details: a) Relationship with the Claimant: b) Monthly Income of the Dependent: c) Affidavit about the dependency upon the Claimant:
13	Whether the claim relates to the treatment as outdoor patient (Attach the following documents) a) Certificate issued/renewed by the competent Board with regard to the chronic ailment b) Authorization by the Competent Authority with regard to the change of the option	Yes No
14	Admissible amount of reimbursement as per Calculation Sheet (Annexure 'A')
15	Amount of Medical Advance given, if any
16	Balance Amount

Page 5: Affidavit (First)

Affidavit Details: I, Rajesh Kumar Sharma S/o Sh. Ramesh Chand Sharma R/o House No. 245, Sector 15, Chandigarh, am working as TGT (Mathematics) in Government Senior Secondary School, Sector 15, Chandigarh, District Chandigarh. I, the above named deponent, do hereby solemnly affirm and declare as under: 1. That I am claiming the present medical reimbursement claim from the department. 2. That I have not received any claim from any insurance company. 3. That, in case, any claim/information is found incorrect, I shall be ready to face criminal proceeding and departmental inquiry. 4. That I shall be solely held responsible for any financial fraud, if committed in this regard in whatsoever manner.

Date: Place:

Deponent


Rajesh Kumar Sharma

VERIFICATION

It is verified that the contents of Para No. 1 to 4 of the above my affidavit are true and correct to my knowledge. Nothing relevant has been kept concealed therein.

Date: Place:

Deponent


Rajesh Kumar Sharma

Page 6: Affidavit (Second)

Affidavit Details: I, Rajesh Kumar Sharma S/o Sh. Ramesh Chand Sharma Resident of House No. 245, Sector 15, Chandigarh, District Chandigarh do hereby solemnly affirm and declare as under: 1. That I am working as TGT (Mathematics) in Government Senior Secondary School, Sector 15, District Chandigarh. 2. That my wholly and solely dependent Mother Smt. Kamla Devi is solely dependent on me and is residing with me. My Mother age is 68 years. 3. That my wholly and solely dependent Mother is having income not more than Rs. 3500/- per month. 4. That neither me nor my wholly and solely dependent mother has received any claim neither from any employer nor from any insurance company in whatsoever manner. 5. That in any case claim/information is found incorrect I shall be ready to face criminal proceeding and Departmental inquiry. 6. That my Mother remained admitted in GMCH-32, Chandigarh as an indoor patient for treatment for the period 20/08/2025 to 25/08/2025. 7. That during the aforesaid period of treatment in this Hospital, I have incurred the expenditure of Rs. 3,800/- on Hospital Medicine bill and Medical test bill. 8. That I shall be solely held responsible for any financial fraud, if committed in this regards in whatsoever manner and I shall deposit the amount claimed along with interest in the state exchequer.

Date: Place:

Deponent


Rajesh Kumar Sharma

Verification

It is verified that the contents of para No. 1 to 8 of the above my affidavit are true and correct to the best of my knowledge and nothing relevant has been kept concealed therein.

Date: Place:

Deponent


Rajesh Kumar Sharma

Page 7: Certificate

It is certified that I have verified the contents of the affidavit and income certificate submitted by Sh. Rajesh Kumar Sharma, designation TGT (Mathematics), serving in Government Senior Secondary School, Sector 15, Chandigarh, District Chandigarh in regard to solely & wholly dependent medical claim for the medical treatment of Smt. Kamla Devi. Relation with the employee: Mother. As per verification the case is genuine and the same is recommended for reimbursement.

Principal


(Signature & Seal)

Block Education Officer


(Signature & Seal)

District Education Officer


(Signature & Seal)

Page 8: Annexure "A" - Calculation Sheet

Name:

Designation:

Office:

Name of Disease:

Name of Hospital:

Duration:

Sr.	Description	Cash Memo No. & Date	Gross Amount	Admissible Amount	Non-Admissible Amount	Balance	75% of Balance	Total Admissible	Action
1
2
3
TOTAL ADMISSIBLE AMOUNT:

Prepared by Dealing Assistant


(Signature)

Checked by Superintendent


(Signature)

Verified by SO O/o DEO


(Signature)

Approved & Counter Signed


(Signature)