ಕರ್ನಾಟಕ ಸರ್ಕಾರದ ವೈದ್ಯಕೀಯ ವೆಚ್ಚ ಮರುಪಾವತಿ ದಾಖಲೆಗಳು ಮತ್ತು ಚೆಕ್‌ಲಿಸ್ಟ್

💡 ಸೂಚನೆ: ಎಲ್ಲಾ ವಿವರಗಳನ್ನು ಭರ್ತಿ ಮಾಡಿ ಮತ್ತು ಚೆಕ್‌ಲಿಸ್ಟ್ ಬಾಕ್ಸ್‌ಗಳ ಮೇಲೆ ಕ್ಲಿಕ್ ಮಾಡಿ ಸರಿ (✔) ಅಥವಾ ತಪ್ಪು (✖) ಆಯ್ಕೆ ಮಾಡಿ. ನಂತರ ಪ್ರಿಂಟ್ ಬಟನ್ ಒತ್ತಿ. ಬದಲಾವಣೆಗಳು ಆಟೋ-ಸೇವ್ ಆಗುತ್ತವೆ.

ಕರ್ನಾಟಕ ಸರ್ಕಾರದ ನೌಕರರ ವೈದ್ಯಕೀಯ ವೆಚ್ಚ ಮರುಪಾವತಿ ಅರ್ಜಿ ಮತ್ತು ದಾಖಲೆಗಳ ಸಂಕೀರ್ಣ

-: ವೈದ್ಯಕೀಯ ವೆಚ್ಚ ಮರುಪಾವತಿ ಚೆಕ್‌ಲಿಸ್ಟ್ :-

ಶಿಕ್ಷಕರ ಹೆಸರು:

ರೋಗಿಯ ಹೆಸರು:

ಚಿಕಿತ್ಸೆ ಪಡೆದ ಆಸ್ಪತ್ರೆ:

ಶಿಕ್ಷಕ-ರೋಗಿಯ ಸಂಬಂಧ:

ಪಡೆದ ವೈದ್ಯಕೀಯ ಚಿಕಿತ್ಸೆ:

ಅ.ನಂ.	ಪರಿಶೀಲಿಸಬೇಕಾದ ವಿವರಗಳು	ಸರಿ/ತಪ್ಪು

FORM "A" (VIDE RULES)

CERTIFICATE

I certify that of employed on the has been under my treatment for disease in the Hospital and that the service special nurses for which an expenditure of Rs. (Rs. ) was incurred vide bills and receipts attached were essential for the recovery in condition of the patient.

Medical Superintendent
Signature of Medical Officer In charge of the case of the hospital

FORM "AA" (VIDE RULES 9(i))

Form of certificate to be produced by a Government Servant under rule (9) (i) Government Servants Medical Attendance Rules 1963.

CERTIFICATE

This is to certify that working as in the office of is a Govt. Servant to whom the Karnataka Govt. Servants (Medical Attendance) Rules 1963 applied. Therefore he/she and members of his family are entitled for medical attendance and treatment.

His total emolument of Rs. P.M. The details of which are as follows:

Pay:

DA:

HRA:

MA:

EX-GR:

Gross Salary:

Signature & Designation
Head of office or any other Officer belong to the office

Declaration of Government servant regarding a dependent:

I hereby declare that is a member of my family as defined under the Karnataka Government Servants' (Medical Attendance) Rules and is Wholly Dependent upon me. He/She is my .

Signed before me:

Signature and Designation of the Head of Office or any other Gazetted Officer.

Signature and Designation of the Government Servant

KARNATAKA MEDICAL DEPARTMENT - FORM B (Vide Rule 15(4))

ESSENTIALITY CERTIFICATE

I hereby certify that Smt/Sri employed in the Department as at has been under my treatment for disease from to hospital/my consulting room and that the under mentioned medicines prescribed by me in this connection were essential for the recovery/prevention of the serious deterioration in the condition of the patient.

Sl. No.	Name of the medical shop, Cash, Receipt No and Dated	Name of the Medicines	Price Rs. Ps
1
2
3

Place:

Date:

Signature of the Medical Officer, In charge of the case at the Hospital
Signature and Designation of the authorized Medical Attendant

FORM 'C' [Vide Rule 15(3)]

Application Form for Claiming Refund of Medical Expenses

1. Name and designation of the Government servant:

2. Office in which employed:

3. Salary:

4. Place of duty:

5. Full residential address:

6. Name of the Patient and relationship (with age if child):

7. Place at which the patient fell ill:

8. Nature of illness and its duration:

9. Details for the amounts claimed:

10. Total amount claimed:

11. List of enclosures:

12. Countersignature by the controlling officer:

Declaration to be signed by the Government Servant:

(1) I hereby declare that the statement 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 and wholly dependent upon me.

(2) I also declare that my wife/husband is not an employee of any State/Central Government OR is employed in and this claim has not been and will not be preferred by my wife/husband.

Signature of the Govt. Servant

FORM 'D' [See rule 15(5)] & FORM 'E' [See Rule 15(6)]

FORM 'D' (Spectacles):

I hereby declare that this is the time that I have claimed refund in respect of spectacles for me/my Sri/Smt. who is a member of my family.

Signature of Government servant

FORM 'E' (Dentures):

I hereby declare that I have not at any time during my entire service claimed refund in respect of full set of dentures for me/my Sri/Smt. who is a member of my family.

Signature of the Government Servant

ದೃಢೀಕರಣ ಪತ್ರಗಳು (Declaration Certificates)

1. ವಿಮಾ ಸೌಲಭ್ಯ ಪಡೆಯದಿರುವ ಬಗ್ಗೆ:

ಶ್ರೀಮತಿ/ಶ್ರೀ ಶಾಲೆ ಹುದ್ದೆ ಇವರು ಆಸ್ಪತ್ರೆಯಲ್ಲಿ ತಮ್ಮ/ಮಗನ/ಮಗಳ/ತಾಯಿಯ/ತಂದೆಯವರ ವೈದ್ಯಕೀಯ ಚಿಕಿತ್ಸೆಗಾಗಿ ರೂ. ಕ್ಕೆ ಸಂಬಂಧಿಸಿದ ಖರ್ಚು ಮಾಡಿರುತ್ತಾರೆ. ಸದರಿ ವೈದ್ಯಕೀಯ ವೆಚ್ಚವನ್ನು ಸದರಿ ಶಿಕ್ಷಕರು/ಶಿಕ್ಷಕಿಯರು ವಿಮಾ ಅಥವಾ ಇನ್ನಿತರ ಯಾವುದೇ ಮೂಲಗಳಿಂದ ಪಡೆದಿರುವುದಿಲ್ಲ ಎಂದು ದೃಢೀಕರಿಸಿದೆ.

2. ಪತಿ/ಪತ್ನಿ ಸರ್ಕಾರಿ ನೌಕರರಲ್ಲದಿರುವ ಬಗ್ಗೆ:

ಶ್ರೀಮತಿ/ಶ್ರೀ ಶಾಲೆ ಹುದ್ದೆ ಇವರು ಆಸ್ಪತ್ರೆಯಲ್ಲಿ ತಮ್ಮ/ಮಗನ/ಮಗಳ ವೈದ್ಯಕೀಯ ಚಿಕಿತ್ಸೆಗಾಗಿ ರೂ. ಖರ್ಚು ಮಾಡಿರುತ್ತಾರೆ. ಸದರಿ ಶಿಕ್ಷಕರ/ಶಿಕ್ಷಕಿಯರ ಪತಿ/ಪತ್ನಿ ಸರಕಾರಿ ನೌಕರಿಯಲ್ಲಿ ಇರುವುದಿಲ್ಲ ಎಂದು ದೃಢೀಕರಿಸಿದೆ.

3. ಪತಿ/ಪತ್ನಿ ಇಬ್ಬರೂ ಸರ್ಕಾರಿ ನೌಕರರಾಗಿದ್ದು ಒಂದು ಕಡೆ ಮಾತ್ರ ಮರುಪಾವತಿ ಕೋರುವ ಬಗ್ಗೆ:

ಶ್ರೀಮತಿ/ಶ್ರೀ ಶಾಲೆ ಹುದ್ದೆ ಇವರು ಆಸ್ಪತ್ರೆಯಲ್ಲಿ ವೈದ್ಯಕೀಯ ಚಿಕಿತ್ಸೆಗಾಗಿ ರೂ. ಖರ್ಚು ಮಾಡಿರುತ್ತಾರೆ. ಸದರಿ ಶಿಕ್ಷಕರ/ಶಿಕ್ಷಕಿಯರ ಪತಿ/ಪತ್ನಿ ಸರಕಾರಿ ನೌಕರಿಯಲ್ಲಿ ಇದ್ದು ಶಾಲೆ/ಕಚೇರಿಯಲ್ಲಿ ಕಾರ್ಯನಿರ್ವಹಿಸುತ್ತಿದ್ದಾರೆ. ಸದರಿ ವೈದ್ಯಕೀಯ ಮರುವೆಚ್ಚದ ಪ್ರಸ್ತಾವನೆಯನ್ನು ಎರಡು ಕಡೆ ಸಲ್ಲಿಸಿರುವುದಿಲ್ಲ ಎಂದು ದೃಢೀಕರಿಸಿದೆ.

CREATED BY :MANOHAR R KGF