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ESSENTIALITY

CERTIFICATE

I certify that Mrs. / Mr./ Miss____________________________________ Wife/ Son/Daughter of Mr.______________________________________________ employed in the _______________________________________________ has been under my treatment for _______________________________________________________________ deceases from Hospital and that the under (my consulting room) mentioned medicines prescribed by me in this connection were essential for the recovery________________________________ (prevention of serious deterioration in the conditions) of the patient. The medicines are not stocked in the ______________________________________ (Hospitals for supply to patients) and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available or preparations which are primarily foods, toilets or disinfectants. Name of Medicines 1.__________________________ Price ________________

2. __________________________ Price ________________ 3. __________________________ Price ________________ 4. __________________________ Price ________________

Signature of the Medical Officer ­in ­Charge in the case of the Hospital.

Signature and Designation of authorized Medical Attendant

A.

Essentiality Certificate: 1. The Essentiality Certificate should be filled in by the Authorized Medical

Attendant himself in the prescribed form. 2. Separate certificate should be produced in respect of the treatment given to

each member of the family by the claimant. 3. The Essentiality Certificate should be signed only by the authorized Medical

attendant who actually gives the treatment. 4. 5. Any certificate countersigned by A.M.O who is not A.M..A shall be rejected. It shall be the responsibility of the A.M.A to exclude preparations which are

primarily in the nature of foods, toilets, or disinfectants. He should indicate in his certificate which of the items included in the vouchers come under these categories.

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6.

Name of the patient, relationship with the Government servant in case of the

family member, disease, period of treatment and place of treatment should carefully and clearly written by the A.M.A himself in the Essentiality Certificate. 7. The names of medicines with their cost should clearly be shown in the

Essentiality Certificate by the A.M.A. The names of medicines which are not eligible shall be disallowed. B Bills in Original given to the Claimant by the Druggist and Dispensing Chemists 1. (i) Bills produced on white papers whether it is with or without seal of the Druggists shall be rejected. (ii) The bill should be a cash voucher only. (iii) Each original bill should contain the name of the claimant or patient and the date of issue. (iv) The name of the drug and its cost should be legibly written. 2. The claimant should prepare typed duplicate copy of each bill and send it along

with his application. The duplicate copy or copies of the bill will be retained in his office with the connected file. 3. The authorized Medical Attendant should countersign both the original and true

copies of the bills. He should affix his seal not only to these bills but also to the Essentiality Certificate. 4. The sanctioning authority should personally satisfy himself: ­ (a) That the essentiality certificate and the bills produced by the claimant are genuine, (b) That the dates of bills and the vouchers are within treatment periods mentioned in the Essentiality Certificate. (c) That preparations which are in the nature of primarily foods, toilets, and disinfectants are excluded, and (d) That the claim is in accordance with the rules in force during the period of treatment. 5. Original bills produced by the claimant should be initialed by the sanctioning authority or by any gazetted officer under him who deals with the application and then returned to the claimant. 6. The claimant should surrender the original bills an the Essentiality Certificate to the Treasury who disburses the bills amount.

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APPENDIX ­IV VIDE RULE 7(4) (V) (B) List of medicines recommended for use by local registered medical practitioners. APPENDIX ­ IV (Vide Rule 19 (1) in part-I) Rule regulating admission of Tuberculosis patients in Govt. Tuberculosis Institutions and other Govt. Medical institutions where there are Tuberculosis wards.

APPENDIX-VI ­ PART- I (Vide Rule 20) (The Andhra Pradesh Rules of Advance for Medical Attendance and Treatment) The advances shall be regulated by the following rules: 1. These rules shall be called the Andhra Pradesh Rules of advances for Medical Attendance and Treatment. 2. These rules shall apply to all the Non-Gazetted Employees of the State.

3. The Advance may be granted to Non-Gazetted Employees of the State meet expenses of medical attendance and treatment to himself or any member of his family which he is entitled to be reimbursed from the State funds under the Medical Attendance Rules. 4. The advances shall be treatment like advance of Traveling allowance and pay on transfer and the recovery must be affected by adjustment from the claim for reimbursement of medical expenses. The matter has been considered carefully, keeping in the changed conditions the Drawing and Disbursing officers, and the Treasury Officers and the pay and Accounts Officer are hereby directed to treat the advance for Medical treatment as an advance of T.A and pay on transfer and efforts shall be made that such an advance for medical treatment is adjusted with I the time stipulated, at avoid probable objections at a later date. (G.O Ms. No. 5436AL/82-1 Dated: 30-03-1982. 5. The Head of the office competent to draw pay bills of his office, may sanction, draw and disburse the advance to all the Non-Gazetted employees working under him where the Head of an Office drawing pay bills happens to be the officer immediately superior to him but the may himself draw the advances. 6. The amount of the advance shall be limited to the amount required to meet actual reimbursable medical expenses certificate by the authorized medical attendant of the employees or by the nearest assistant Surgeon subject to a maximum of Rs. 50/- at a time. If the sanctioning authority is satisfied that the case is emergent, he may sanction an advance up to a maximum limit of Rs. 50/- without insisting upon completion of necessary formalities. (G.O. Ms. No. 317.M &H Dated: 14-04-1975). 7. When an advance is sanctioned to a non permanent Govt. employee it has to be drawn and disbursed to him only after a bond in form-II of the Andhra Pradesh Financial code. Volume ­I is executed by him together with the surety of permanent Govt. servant drawing a pay not less than the borrower.

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8.

(a) The advance should be adjusted in full within a period of three months form the date of drawl of the advance by presenting the claim in the form prescribed under the Medical attendance Rules irrespective of the fact that the treatment last for more than three months. The claim should be furnished to the Director of medical and Health Services or the Special Officer, Indian Medicine, as the case may be, through the authorized medical attendant and the Medical Officer who gave the treatment. After the claim is received back from the Director of Medical and Health Service/Special Officer Indian Medicines, it should be presented to the Treasury or the AccountantGeneral, Andhra Pradesh, as the case may be, by the Heads of Officers for adjustment against advance drawn. (b) A second advance of this kind should not be granted until the fist one has been fully adjusted. The bill for the 2nd advance should be accompanied by a certificate from the sanctioning authority that the previous advance has been adjusted in full. If the advance is not adjusted or returned within a period of three months. It should summarily be recovered form his salary.

9. When any portion of the claim for reimbursement of medical expenses is for any reason disallowed, such amount should be recovered from the salary of the individual in four installments starting with the pay drawn immediately after the claim has been disallowed. 10. In every office the drawl of these advances should be recovered in the register of temporary advances and their recovery by adjustment or refund should be watched. When a borrower is transferred to a new office the details of the advance should be entered in the L.P.C of the individual and the entry in the register should be closed. In the new office which the borrower joins, the particulars of the advance should be entered in the register and the recovery watched. 11. Ordinarily not more than one advance shall be granted in respect of the same illness or injury, but when amount of the fist advance has already been spent, a second advance can be sanctioned when the sanctioning authority is satisfied that eh previous advance has already been spent and Medical Office concerned has certified the necessary of further expenditure. The total amount of both the advance shall not exceed Rs. 50/- or four month's pay whichever is less. There is no objection to the borrower if a claim for the adjustment of the first advance (G.O. Ms. NO 1274 M&H (K1) Dated: 29-12-1978). 12. The term "pay" for this purpose shall mean the pay actually drawn including personnel pay, as on date of application but shall exclude special pay. I. Civil Advances

II. The advance granted under these rules should be accounted for under new subhead Advance fro medical Attendance and treatment to be opened under the head III. Deposits advances

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CERTIFICATE TO BE FURNISHED BY THE MEDICAL OFFICER UNDER RULE 6

Certified that Sri/Smt. _________________________________________ a member of the family of Sri/Smt. Working as ______________________________________ in the office of ______________________________________ at _______________________ is suffering from ____________________________ and that a sum of Rs.__________________________ (Rupees) only is necessary as advance to cover the medical expenses reimbursement by govt. in this case.

Date

:

Signature & Designation

Station :

Certificate by Medical Officer under Rule II Certified ________________________________________ that _______________________ Sri/Smt. __________________________________ a member of _______________________ working as __________________________________ in the office of the ________________ and that a further sum of Rs. _______________ ((Place) is still suffering from ____________ and that a further sum of Rs. _______________ (Rupees _____________________________ only is necessary as advance to cover the reimbursable medical expenses in this cases as from this date.

Date: Station:

Signature & Designation

Note: Strike off the necessary portion when the certificate relates to the Govt. Employees himself. ---------------------------------------------------------------------------------------------------------------Medical Attendance­ Supply of medicines facilities of admission and treatment to pensioners ­ Orders ­ Modified. ----------------------------------------------------------------------------------------------------------------

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APPENDIX ­II Application for claiming refund of Medical expenses incurred in connection on with medical attendance and or treatment of Government Service and their families. 1. Name and Designation & Section of Govt. Servant (in BLOCK letters)3 Officer in which employed :

2. 3.

:

Pay of the Govt. Servant as defined in : F.R.S and other employment which should be shown separately. Place of duty Full residential address with Door No and Name of the Mohalla : :

4. 5.

6.

Name of the patient him/her relationship to : the Govt. Servant in case of children state age also Place at which patient fall ill Nature of illness and its duration : :

7. 8. 9.

Details of amount claimed, cost of : medicines purchased from the market, list of medicines cash memos and the essentially certificate should be attached each in duplicate signed by treatment doctor. Total amount claimed List of enclosures : :

10. 11.

Declaration to be signed by the Govt. Servant I hereby declare that the statement in this application are true to the best of my knowledge and belief and that the person from whom medical expenses were incurred is a member of my family as defined under the Govt. Servant Medical attendance rules and wholly department upon me.

Signature of Govt. Servant & Office to which attested

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CERTIFICATE ­ A (To be completed in the case of patient who are not admitted to hospital for treatment)

Dr._____________________________________________________ hereby certify (a) That I charged Rs.____________ for ______________________________ consultation on ________________ at my consultant room/ at residence of the patient. (b) That I charged Rs.____________ for administering _________________intramuscular / intravenous / subcutaneous injections on _____________________ (Does to be given) at my consulting room at the residence of the patient. (c) That injections administered repay in formatting or propy location purpose. (d) That the patient has been under treatment at _______________________ hospital / consulting room at the under mentioned medicines prescribed by me in this connection were essential for the recovery/ prevention of service deterioration I the condition of the patient. The medicines are not stocked in the _____________________ hospital and don't include propriety preparations for which cheaper substance of equal therapeutic value are available preparations which are primarily foods, tonics, toilets or disinfectants. Name of the Medicine 1. 2. 3. Cost not

(e) That patient/ was suffering from _________________________ and is /was under my treatment from ______________________________ That the patient was/not given penetration post treatment that the X- ray, laboratory tests etc., for which an expenditure of Rs.______________ was incurred was necessary and was under taken on my active at the _______________ (Name of the hospital or laboratory) (f) That referred the patient of Dr. _______________________________ for specialist mutilation and that the necessary approval of Director, Medical service as required under the rules was obtained and (g) That patient didn't require /required hospital etc.

Date:_____________

Signature and Designation of the authorized Medical attendant

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DECLATION

TO BE SIGNED BY THE GOVT. SERVANT

I hereby declare that the statements in this application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is a member of my family as defined under the Andhra Pradesh Govt. Servants Medical attendance Rules 1972, and wholly dependent upon me.

Signature of Govt. Servant

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ESSENTIALITY

CERTIFICATE

I certify that Mrs. / Mr./ Miss____________________________________ Wife/ Son/Daughter of Mr.______________________________________________ employed in the _______________________________________________ has been under my treatment for _______________________________________________________________ deceases

from_____________ to __________________ at _________________________ Hospital and that the under (my consulting room) mentioned medicines prescribed by me in this connection were essential for the recovery________________________________ (prevention of serious deterioration in the conditions) of the patient. The medicines are not stocked in the ______________________________________ (Hospitals for supply to patients) and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available or preparations which are primarily foods, toilets or disinfectants. Name of Medicines 1......................................... Price............................ 2.........................................Price.............................

Signature and Designation of authorized Medical Attendant

Signature of the Medical Officer ­In ­Charge in the case of the Hospital.

This is to certify that Mr. /Mrs/ Ms_______________________________ S/O / D/O / W/O _________________________ aged about _________________________ admitted in our hospital in _______________________ Department under emergency on __________ at _____________ am/pm. The provisional diagnosis is ________________________________

Signature and Designation of the attendance medical authority

Note: The emergency certificate issued by Private Hospitals be scrutinized and counter signed by DME Education

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NON- DRAWAL CERTIFICATE

Certified that the claim or reimbursement of medical expenses incurred by Sri.______________________________ retired/working as _____________________ on his treatment for ________________________ from __________________ to _____________ at _________________________________ hospitals (Rupees _________________________ ________________ only) was neither preferred nor drawn previously.

Signature and Designation

ADVANCE CERTIFICATE (Certified to be furnished by the Medical Officer under Rule 6)

Certified that Sri/ Smt. _________________________ a member of the family of Sri/Smt. Working as _________________________ in the office of ____________________ at ___________________________ is suffering form __________________ and that a sum of Rs. ___________ (Rupees ___________________________________ only ) is necessary as advance to cover the medical expenses reimbursement by the Government in the case

Date:

Signature

State:

Designation

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ADVANCE CERTIFICATE FOR SECOND TIME TREATMENT (Certificate by Medical Officer under Rule II)

Certified that Sri/Smt.___________________________ a member of the family of Sri/ Smt __________________________ working as __________________________ in the office of the ________________________ at __________________________ (Place) is still

suffering from ___________________________ and that a further sum of Rs.____________ (Rupees _____________________________________________ only) is necessary as advance to cover the reimbursable medical expenses in this case s from this date.

Date:

Signature:

State:

Designation:

Note: Strike off unnecessary portion when the certificate relates to the Government Employees himself

DECLARATION

CERTIFICATE

I _________________________________________ (Full name & Designation) hereby declare that my father/ mother, Sri/Smt ______________________________ has no property or income of his /her own and that he/ she is wholly dependent upon me.

Station_________________________

Date:

Signature & Designation

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CHECK LIST FOR SUBMISSION OF MEDICAL

ADVANCE / REIMBURSEMENT

1. 2. 3. 4.

Name of the employee and Designation

:

Name of the patient and relationship with employee : Name of Disease :

Whether disease covered in G. O. Ms. No. 86 : Fin. & Plg Dated: 01-06-1992. If so, admissibility certificates should be enclosed Whether the patient has been referred to NIMS/ SVIMS in case the disease is not covered in G. O. Ms. No. 86 Dated: 01-06-1992 Whether the patient underwent treatment hospital is a recognized hospital as per Govt. orders Whether the patient has been referred by NIMS/ SVIMS is case of treatment taken in the hospital recognized :

5.

6. 7.

: :

8.

If not referred by NIMS/SVIMS, justified reasons : and nature of the urgency of obtaining treatment in recognized hospital as per G. O. 175 H & M Dated: 29-05-1997. Whether enclosed estimation certificate in case of advance essential certificate in case of retirement Whether bills have countersigned by concerned Had of Department NIMS/ SVIMS in case of medical reimbursement Amount of advance / reimbursement required, in case of reimbursement in various hospitals separate station to be shown Whether the claim has been referred within (6) months) Remarks of recommending officer : :

9. 10.

11.

:

12. 13.

: :

Signature of the Recommending Officer

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EMERGENCY

CERTIFICATE

This is to certify that _________________________________________ male/ female patient was admitted in our hospital on __________________ in emergency. He has been discharged on _______________________ his admission is essential.

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Hospital No: _______________ BILLING STATEMETN Date Bill No Date & Place of purchase of investigation (3) Medicine name /Investigation done (4) Qty Rate Discount Total Amount

(1)

(2)

(5)

(6)

(7)

(8)

(Rupees _______________________________________________________________only)

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