For O.P.D.

Treatment only

INDIAN INSTITUTE OF TECHNOLOGY GUWAHATI

Medical Claim Form
Application for claiming refund of medical expenses incurred in connection with medical
attendance and treatment of students, members of staff of the Indian Institute of Technology
and their families. (N.B. separate form should be used for each patient)
Total no. of sheets including this:=

*I. Status Information for the claimant (in Block Letters) -

a) Name (IN BLOCK LETTERS) :

b) Designation with Emp No./Roll No. :

c) Department/ Section/ Centre/ Cell :

d) Pay (In case of employee) :

e) Bank A/c no., IFSC, Bank name and :

branch

f) Residential Address
g)

II. Information regarding the patient:

a) Name of the Patient & Relationship :

b) Illness :

c) Since when ill & place where ill :

III. Amount claimed and details thereof:

a) Number and dates of consultation and the fee

paid for each consultation
(i) Date of Consultation :

(ii) Fee paid for each visit :

b) Name & Designation of Medical Officer consulted :

c) Hospital/ Dispensary attached :

d) Whether consulted at Hospital/ consulting Room :

of Doctor/ Residence

e) Fee paid for each consultation :

*indicates mandatory information

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IV. Charges for Pathological, Bacteriological, Radiological or other similar tests undertaken, during
diagnosis indicating:

a) Name of Hospital or Laboratory where tests :

undertaken

b) Whether tests undertaken on advice of the :

authorized Medical Attendant (If so, attach
certificate)

Cost of Medicines purchased from market (List and

1. c) :
cash memos to be attached) as also essentiality
certificate countersigned
by_________________________________
No. of Cash Memos attached (* Please submit
(i) :
Cash Memo/ Bills in original only)

Total amount claimed (in ₹) :

Total Number of enclosures :

DECLARATION TO BE SIGNED BY THE EMPLOYEE/STUDENT

I hereby declare that the statement made in this application are true to the best of my knowledge and belief/ and
that the person for whom medical expenses were incurred is wholly dependent upon me and is not an earning
member of the family.

______________
Date: Signature

Contact no. ……………………

e- mail id(@iitg.ac.in)…………………….

Countersigned and certified that the claim:

i) is genuine
ii) is covered by the rules and orders on the subject
iii) is supported by bills, receipts and other certificates etc.
iv) was not drawn before and
v) has been sanctioned by me.

Joint Registrar/Assistant Registrar (F&A)

*Indicates mandatory requirement

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 FOR OPD TREATMENT ONLY

ESSENTIALITY CERTIFICATE “A”

Certificate granted to Mr./Mrs./Miss/________________________________________wife / husband/

father/ mother/ son/ daughter_____________________________________________ employed in the
IIT Guwahati.
1. Dr.______________________________________________________________ hereby certify

a). That I charged and received Rs._____________ for consultations on __________________ at

my consulting room/ at the residence of the patient.

b). That I charged and received Rs._______________ for administering intramascular/ sub-
cutanreous__________________________________________ at many consulting room/ at the
residence of the patient.

c). That the injections administered were for / were not for immunizing or prophylactic.

d). That the patient has been under treatment at Hospital/ my consulting room and that the under
mentioned medicines prescribed by me in this connection were essential for the recovery/ prevention
of serious deterioration in the condition of the patient. The medicines are not stocked in the
_________________ Hospital for supply of patients and do not include proprietary preparations for
which cheaper substances of equal therapeutic value are available for preparations of which are
primarily food toilts or disinfectants.

Name of the Medicines Price (Rs.)

.

1.

e). That the patient is/ was suffering from _____________________________________ and is / was
under my treatment from _______________ to ____________________.

f). That the X-ray, Laboratory Test etc. for which the expenditure of Rs.________________ was
incurred were necessary and were undertaken on my advice at the _____________ hospital
laboratory.

g). That I referred the patient to Dr.____________________________________ for special

consultation and

h). That the patient did not require/ required hospitalization.

i) *Lab Reports : Checked / Not Checked

j) The Admissible amount for reimbursement: ______________________

Date________________ Signature & Designation of

the Medical Officer
Regn. No.

N.B. : Certificate not applicable should be struck off certificate is compulsory and must be filled in by
the Medical Officer in all cases
*Indicates mandatory