Title: CURICULUM VITAE
Author: Rafi
Last saved by: Ali Bugti
Company: Sweet Home

APPLICATION FORM FOR REIMBURSEMENT OF MDEDICAL CHARGES IN RESPECT OF SERVING/RETIRED GOVERNEMTN SERVANT AND HIS/HER DEPENDENTS

PART-A
1.	Name 							 Designation 					 BPS No.		  of the Serving/retired Federal Government Servant, (Alive/Deceased).
2.	Name of the patient 							 & relationship with the claimant 						 as dependent, as specified in rule 2(d) of the Federal Government Medical Attendance Rules, 1990.
3.	Diagnosis of the patient 										.
4.	Name of institution of the serving/retire Govt Servant at S. no.1  																			.
5.	Vendor no. and PPO no. for retired 									.
	(Also attached pension payment order for verification of PPO no.)	

PART-B
Certificates by Govt. Servant (or member of his family in case of deceased Govt. Servant)
Certified that: -
(i)	The member(s) of my family for whose treatment reimbursement has been claimed is wholly dependent upon me.
(ii)	The claim was not drawn before.
(iii)	I shall have no objection to the recovery of any mount overpaid, if any, from my pay/pension or otherwise.

Signature 				
Full name of the Govt. Servant or
(Claimant family member in case of deceased)

Dated: 					 								
									      (IN BLOCK LETTERS)

CERTIFICATE BY THE AUTHORISZED MEDICAL ATTENDAT
	Certified that the medicines/drugs/hospitalization/clinical tests/examinations listed below were essential for the recovery and restoration of the patient, Mr/Mrs/Miss 																			
2.	It is further certified that neither the medicines/drugs etc nor their effective substitutions could be supplied from the hospital/dispensary.

Signature 				
Designation 				
Dated: 								Official Stamp 			

COUNTERSIGNATURES 

Departmental Controlling Authority				Hospital Authority
Signature 								Signature 				
Designation 								Designation 				
Official Stamp 							Official Stamp 			

Cont …. P/2

-2-

S no.

No. & date of bill / Cash memo

Name of Chemist Shop / Hospital / Clinic/Dispensary

Name of Drugs / Medicines with Quantity/Details of Tests etc

Amount
Rupees

| | | Name of Drugs | Quantity |

Dated: 									Signature 				

								(FULL NAME OF THE GOVT. SERVANT)