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    Medical Form

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    Asim Malik
    Medical performa for reimbursement of medical charges through AGPR for government employee of pakistan

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Medical Form

    Uploaded by

    Asim Malik
    290 views2 pages
    Medical performa for reimbursement of medical charges through AGPR for government employee of pakistan

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    Medical form

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    Medical performa for reimbursement of medical charges through AGPR for government employee of pakistan

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    290 views2 pages

    Medical Form

    Uploaded by

    Asim Malik
    Medical performa for reimbursement of medical charges through AGPR for government employee of pakistan

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    APPLICATION FORM FOR REIMBURSEMENT OF MEDICAL CHARGES IN RESPECT OF

    SERVING/RETIRED GOVERNMENT SERVANT AND HIS/HER DEPENDENTS

    PART-A

    1. Name, designation, BPS, of the serving/retired Federal Government servant, (Alive/Deceased)


    ------------NAJAM UL HASSAN SHAH, UDC (BS-
    11)--------------------------------------------------------------------
    2. Name of the patient and relationship with the claimant as dependent, as specified in rule 2(d) of the
    Federal Service Medical Attendance Rule, 1990 Self
    3. Diagnosis of the patient _ -_______ __________________________
    4. Ministry/Division/Department/Office of the serving/retired Government Servant at S.No.1
    Ministry of Communication, National Highways & Motorway Police
    5. Vendor No. and PPO No. for retired
    6. List of medicines with quantity/hospital bill/laboratory and other diagnostic charges etc for which
    reimbursement is claimed through this bill (format attached)

    PART-B

    Certificate by Government servant (or member of his family in case of deceased Government 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 amount overpaid, if any from my pay/pension
    or otherwise.

    Signature
    NAJAM UL HASSAN SHAH
    ___________________________________________
    (IN BLOCK LETTERS)
    Date:

    CERTIFICATES BY THE AUTHORIZED MEDICAL ATTENDANT

    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. not their effective substitutes could be
    supplied from the hospital/dispensary.

    Signature
    Designation
    Dated: ________ Official Stamp

    COUNTERSIGNATURES

    Departmental Controlling Authority Hospital Authority


    Signature Signature
    Designation Designation
    Official Stamps Official Stamps
    Name of the Name of
    Amount
    S/N Bill # Date Chemist/Shop/Hospital/ Drugs/Medicines/Details of Quantity
    (Rs)
    Clinic/Dispensary Test etc.
    S.No. Name Beat Remarks

    1 08
    CPO Waqar Javed

    2 08
    SPO Saleem Elahi

    3 08
    SPO Malik Ahmed Khan

    4 05
    SPO Haroon Wazir

    5 05
    APO Rafi Ullah

    6 06
    JPO Ahmed Mujtaba

    Signature:
    ________________________________________________________
    Full Name of the Government Servant

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