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Bank Account No. S.B.P. Thermal Plant A/C No.

Employee Code :

E S S E N T I A L I T Y C E R T I F I C A T E
(To be filled in Capital Letters)
Name of Claimant _____________________________period of treatment
Designation ___________________From ______________To_____________
Department ___________________Outdoor No. _____________Dt._______
Pay _________________Indoor No. __________________Dt.____________

I certify that Mr/Mrs. ____________________son/daughter/wife


mother/father of Mr/Mrs. ___________________employed in the office
of the _______________________________has been under my treatment
in the ____________________Hospital/Dispensary in my consultation
room and that the under mentioned medicines prescribed be me in
this connection were absolutely essential in the condition of the
patient, the medicines were not stocked in the___________________
(Name of Hospital/Dispensary) for the supply to the patient, and
do not include preparation 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 the Govt.
orders issued on this subject from time to time.
5.He/She was suffering from______________________________________
-----------------------------------------------------------------
Sr.No. Name & Quantity of Outdoor ticket Dt. on Price
medicines No. & dt. on actually
(In capital letters) which prescribed purchased Rs. P.
-----------------------------------------------------------------

Signature & Stamp of the A.M.A.


In case of indoor treatment
Certified that the medicines claimed in this bill are as
per head ticket No. _______________relates to the case.

P.T.O.
Certified that:-
--------------
1. The medicines have actually been purchased by me during the
course of treatment.
2. I am living in House No.______________________________________
3. I have purchased the medicines from the prescribed Co-op store.
4. The medicines have been purchased from private shop after
obtaining non availability certificate from___________________
Co-Op Store/Super Bazar _________________________.
5. The amount of medicines purchased from private shop against one
or more prescription does not exceed Rs.50/-in a single day.
6. In case of wife/children
------------------------
That the patient Mr/Mrs. __________________________________is my
_________________and he/she is solely dependent upon me and is
residing with me at _______________and he/she is unmarried and
un-employed in case of sons/daughters.
7. For parents only
----------------
His/her total monthly income does not exceed Rs.750/-P.M. and
mother/father is/are residing at _______________________.
8. In case spouse is working
-------------------------
a) Certified that my wife/husband is not getting any fixed medical
allowance from any source.
b) Certified that wife/husband is employed and is not getting any
medical reimbursement. An affidavit to this effect has already
been furnished.
c) Certify that I am not adhoc employee and a working on regular
basis.

Signature of the Claimant


Name in capital letters_______________
Place. Designation______________________
Dt. Office___________________________
___________________________
Bank Account No. S.B.P. Thermal Plant A/C No.____________________

Employee Code :

E S S E N T I A L I T Y C E R T I F I C A T E
(To be filled in Capital Letters)
Name of Claimant _____________________________period of treatment
Designation ___________________From ______________To_____________
Department ___________________Outdoor No. _____________Dt._______
Pay _________________Indoor No. __________________Dt.____________

I certify that Mr/Mrs. ____________________son/daughter/wife


mother/father of Mr/Mrs. ___________________employed in the office
of the _______________________________has been under my treatment
in the ____________________Hospital/Dispensary in my consultation
room and that the under mentioned medicines prescribed be me in
this connection were absolutely essential in the condition of the
patient, the medicines were not stocked in the___________________
(Name of Hospital/Dispensary) for the supply to the patient, and
do not include preparation 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 the Govt.
orders issued on this subject from time to time.
5.He/She was suffering from______________________________________

Sr. Detail of name & Quantity as Outdoor ticket Dt. on Price


No. per annexure No.& dt. on actually Rs. P.
which purchased
prescribed
1. Annexure - 1(a) medicine 3.08.10 3.08.10 2009.80
2. Annexure - 2(a) medicine 12.08.10 12.08.10 510.00
3. (b) Test Report 12.08.10 12.08.10 100.00
4. (c) Test Report 12.08.10 12.08.10 120.00
5. Annexure – 3.Test Report 12.08.10 12.08.10 1170.00
6. Annexure - 4(a) medicine 14.08.10 14.08.10 1045.00
7. (b) medicine 14.08.10 14.08.10 2157.00
8. (c) medicine 14.08.10 14.08.10 1709.00
9. Annexure - 5(a) medicine 15.08.10 15.08.10 1065.00
10. Annexure - 6(a) medicine 16.08.10 16.08.10 1043.00
11. Annexure - 7. Test Report 16.08.10 16.08.10 300.00
12. Annexure - 8(a) medicine 17.08.10 17.08.10 2748.00
13. Annexure - 9.indoor 17.08.10 17.08.10 15000.00
discharge slip
14. Annexure - 10(a) medicine 18.08.10 18.08.10 35.00
15. Annexure - 11(a) medicine 24.08.10 24.08.10 1346.00
16. Annexure - 12(a) medicine 31.08.10 31.08.10 546.00
17. Annexure - 13(a) medicine 04.09.10 04.09.10 537.00
(b) medicine 12.09.10 12.09.10 288.00

Total Amount.31728.80

Signature & Stamp of the A.M.A.


In case of indoor treatment
Certified that the medicines claimed in this bill are as
per head ticket No. _______________relates to the case.

P.T.O.
Bank Account No. S.B.P. Thermal Plant A/C No.____________________

Employee Code :

E S S E N T I A L I T Y C E R T I F I C A T E
(To be filled in Capital Letters)
Name of Claimant _____________________________period of treatment
Designation ___________________From ______________To_____________
Department ___________________Outdoor No. _____________Dt._______
Pay _________________Indoor No. __________________Dt.____________

I certify that Mr/Mrs. ____________________son/daughter/wife


mother/father of Mr/Mrs. ___________________employed in the office
of the _______________________________has been under my treatment
in the ____________________Hospital/Dispensary in my consultation
room and that the under mentioned medicines prescribed be me in
this connection were absolutely essential in the condition of the
patient, the medicines were not stocked in the___________________
(Name of Hospital/Dispensary) for the supply to the patient, and
do not include preparation 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 the Govt.
orders issued on this subject from time to time.
5.He/She was suffering from______________________________________

Sr. Detail of name & Quantity as Outdoor Dt. on Price


No. per annexure ticket No.& actually Rs. P.
dt. on which purchased
prescribed
1. Annexure – 1.Test Report 31.08.2010 31.08.2010 400.00
2. Annexure - 2(a) medicine 31.08.2010 31.08.2010 975.00
3. Annexure – 3.Test Report 03.09.2010 03.09.2010 400.00
4. Annexure – 4.Test Report 03.09.2010 03.09.2010 410.00
5. Annexure – 5.Test Report 03.09.2010 03.09.2010 450.00
6. Annexure – 6.Test Report 03.09.2010 03.09.2010 50.00
7. Annexure - 7.Test Report 03.09.2010 03.09.2010 100.00
8. Annexure – 8.Test Report 03.09.2010 03.09.2010 120.00
9. Annexure – 9(a)medicine 03.09.2010 03.09.2010 930.00
10. Annexure - 10(a) medicine 03.09.2010 03.09.2010 4390.00
11. Annexure – 11.Test Report 04.09.2010 04.09.2010 300.00
12. Annexure - 12(a) medicine 04.09.2010 04.09.2010 3715.00
13. Annexure - 13(a) medicine 05.09.2010 05.09.2010 3715.00
14. Annexure - 14(a) medicine 06.09.2010 06.09.2010 3673.00
15. Annexure – 15.Test Report 06.09.2010 06.09.2010 300.00
16. Annexure – 16.(a) medicine 07.09.2010 07.09.2010 679.00
17. Annexure -17.indoor discharge 07.09.2010 07.09.2010 18000.00
18. slip
19. Annexure - 18(a) medicine 06.09.2010 06.09.2010 16.00

Total Amount.

Signature & Stamp of the A.M.A.


In case of indoor treatment
Certified that the medicines claimed in this bill are as
per head ticket No. _______________relates to the case.

P.T.O.
Bank Account No. S.B.P. Thermal Plant A/C No.____________________

Employee Code :

E S S E N T I A L I T Y C E R T I F I C A T E
(To be filled in Capital Letters)
Name of Claimant _____________________________period of treatment
Designation ___________________From ______________To_____________
Department ___________________Outdoor No. _____________Dt._______
Pay _________________Indoor No. __________________Dt.____________

I certify that Mr/Mrs. ____________________son/daughter/wife


mother/father of Mr/Mrs. ___________________employed in the office
of the _______________________________has been under my treatment
in the ____________________Hospital/Dispensary in my consultation
room and that the under mentioned medicines prescribed be me in
this connection were absolutely essential in the condition of the
patient, the medicines were not stocked in the___________________
(Name of Hospital/Dispensary) for the supply to the patient, and
do not include preparation 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 the Govt.
orders issued on this subject from time to time.
5.He/She was suffering from______________________________________

Sr. Name & Quantity of medicines Outdoor Dt. on Price


No. ticket No.& actually Rs. P.
dt. on which purchased
prescribed

Signature & Stamp of the A.M.A.


In case of indoor treatment
Certified that the medicines claimed in this bill are as
per head ticket No. _______________relates to the case.

P.T.O.
Certified that:-
--------------
1. The medicines have actually been purchased by me during the
course of treatment.
2. I am living in House No.______________________________________
3. I have purchased the medicines from the prescribed Co-op store.
4. The medicines have been purchased from private shop after
obtaining non availability certificate from___________________
Co-Op Store/Super Bazar _________________________.
5. The amount of medicines purchased from private shop against one
or more prescription does not exceed Rs.50/-in a single day.
6. In case of wife/children
------------------------
That the patient Mr/Mrs. __________________________________is my
_________________and he/she is solely dependent upon me and is
residing with me at _______________and he/she is unmarried and
un-employed in case of sons/daughters.
7. For parents only
----------------
His/her total monthly income does not exceed Rs.750/-P.M. and
mother/father is/are residing at _______________________.
8. In case spouse is working
-------------------------
a) Certified that my wife/husband is not getting any fixed medical
allowance from any source.
b) Certified that wife/husband is employed and is not getting any
medical reimbursement. An affidavit to this effect has already
been furnished.
c) Certify that I am not adhoc employee and a working on regular
basis.

Signature of the Claimant


Name in capital letters_______________
Place. Designation______________________
Dt. Office___________________________
___________________________