APPLICATION FORM OF MEDICAL REIMBURSEMENT FOR WBHJS/WBCS(J) OFFICERS

1. Particulars of the Officer:

          a) Name ( in Block letters)

          b) Service with year of allotment

c) Designation

d) Place of Duty

          e) Residential Address

2. Particulars of the patient

          a) Name of the patient:

          b) Relationship with the Officer Self/Wife/dependent son

c) Age

3. Particulars of the treatment

        a) Nature :

        b) Place where treated :

        c)Period of treatment :

4. Particulars of the attending doctors.

         a) Name(s) of the doctor(s) :

         b) Address :

         c) No. and dates of consultations :

5 Hospitalization if done.

    a) Name of the Hospital/Nursing Home ;

     b) Period of stay in Hospital/Nursing Home :

6. Details of the claim to be supported by cash Memos vouchers etc.

        A. (i) Cost of medicines. : Rs.

            (ii) Cost of Injections : Rs.

  (iii) Charges for Diagnostic tests : Rs.

  (iv) Charges for special Nursing : Rs.

B. Consultation fee if any : Rs.

  ( Particulars to be supported by receipts)

TOTAL CLAIM : Rs.

(Rupees___________________________________________

1. Hospital/Nursing Home Charges ( to be supported by cash memo/voucher etc.)

   1. Rent for cabin/bed Rs.

   2. Surgical Operatuion Rs.

   3. Diagnostic costs Rs.

   4. Medicines Rs.

   5. Consultation Fees Rs.

   6. Nursing Charges Rs.

   7. Charges for special attention Rs.

   8. Ambulance Charges Rs.

   9. Any other charges Rs.

Rupees___________________________________________________only.

DECLARATION

I, Shri ___________________hereby declare that the statements in this application are true to the best of my knowledge and that the person for whom medical expenses are claimed is wholly dependent upon me and that he/she has no independent source of income of his/her own.

                                                                                                                                   ( SIGNATURE OF THE OFFICER )

N.B. : Please score out whichever is not applicable.

Enclosures. 1) Copy/Original medical prescription of the doctor.

2) List of Medicines/Injections purchased.

3) Cash Memos in original as per receipt Nos. and dates given below:-

                                                                                                                                 ( SIGNATURE OF THE OFFICER )

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LISTS OF MEDICINES/INJECTIONS PURCHASED AND CHARGES FOR

DIAGNOSTIC TEST DONE

A) List of Medicines/Injections purchased for the treatment of Shri/Smt.___________________

S. No.	Particulars of the Medicines/ injections purchased.	QUANTUM	RECEIPT NO.	DATE	AMOUNT
TOTAL AMOUNT

B) List if Diagnostic Tests, X-RAY, Sonography and other types of tests, if any got done.

S. No.	Particulars of the Tests Diagnostic tests done.	Receipt No.	Date	AMOUNT
Total amount paid

Amount claimed as per List (A) ... ... Rs.________

Amount claimed as per List (B) ... ... Rs.________

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GRAND TOTAL OF LISTS (A) AND (B) ....................................... Rs._________

LISTS OF MEDICINES/INJECTIONS PURCHASED

List of Medicines/Injections purchased for the treatment of Shri/Smt._____________________

S. No.	Particulars of the Medicines/ injections purchased.	QUANTUM	RECEIPT NO.	DATE	AMOUNT
TOTAL AMOUNT

                                                                                                                                    ( SIGNATURE OF THE OFFICER )

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Application for Reimbursement of 50% of the Electric Consumption charges in terms of

G.O. No.6853-J dated 20^th November, 2007.

_______________________________________________________________________

1. Name and Designation of :

   the Judicial Officer. .

2. Place of Duty :

3. Period of Bill :

4. Total amount paid against the Bill : Rs.

5. 50% of the amount paid : Rs.

6. Total amount claimed : Rs.

7. List of Enclosures :

DECLARATION

Certified that the amount claimed in this bill has actually been paid by me.

                                                                                                                                           ( SIGNATURE OF THE OFFICER )