In lieu of MED.

97
FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURED IN CONNECTION WITH
MEDICAL ATTENDENCE AND/OR TREATMENT OF CENTRAL GOVT. SERVANTS AND THEIR FAMILIES.
N.B.:_ Separate form should be used for each patient.
1. Name and desgn. OfGovt.servant (in block letters): VINIT JAIN, SAO/98335890
2. Office in which employed: LAO (AF) ‘B’ Chandigarh
3. Pay of the govt. servant: Rs. 87,400/- in Level 10
4. Place of duty: Chandigarh
5. Actual residential address: 1212A, Sec 31B, Chandigarh
6. Name of the patient & his relation with Govt servant: Priya Jain, Wife
7. Place at which patient fell ill: Chandigarh
8. Details of the amount claimed:
I. MEDICAL ATTENDANCE:_
(a) The name and desgn. of medical officer consulted -- Dr. Emmy Grewal
and the hospital or dispensary to which attached
(b) The number and dates of consultations and fee One consultation on
paid for each consultation. 17.11.2023, fee paid NIL
(c) The number & dates of injections and the fee NIL
paid for each injection.
(d) Whether consultation and/or injections were held At the Hospital
at the hospital/consulting room of the medical
officer or at the residence of the patient.
II. Charges for pathological/bacteriological/radiological NIL
or other similar tests undertaken during diagnosis indicating:
(a) The name of the hospital or laboratory where
tests were undertaken, and
(b) Whether the tests were undertaken on the advice
of the authorised medical attendant, if so,
a certificate to that effect should be attached.
III Cost of medicines purchased from the market: 1,346/-
(list of medicines/cash memos & the essentiality certificate should be attached)
9. Total amount claimed. Rs1,346/-
10.Less advance taken on NIL
11.Net amount claimed Rs1,346/-

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the 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.

RECEIVED PAYMENT

Dated: 12.02.2024 (VINIT JAIN)

SAO/LAO (AF) ‘B’
Chandigarh

S.No NAME OF MEDICINES COST(Rs)

1 Tab Istamet 50/1000 630.00
2 Tab Glimy 1 mg 124.07
3 Tab Dapavel 10 mg 426.00
4 Tab Lipicure 10 mg 165.99
Total 1,346.00

In lieu of MED.97

FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURED IN CONNECTION WITH
MEDICAL ATTENDENCE AND/OR TREATMENT OF CENTRAL GOVT. SERVANTS AND THEIR FAMILIES.
N.B.:_ Separate form should be used for each patient.
1. Name and desgn. ofgovt.servant (in block letters): VINIT JAIN, AO/8335890
2. Office in which employed: PCDA (WC) Chandigarh
3. Pay of the govt. servant as defined in fundamental rules and
any other emoluments which should be shown separately: Rs. 75,600/- in Level 9
4. Place of duty : Chandigarh
5. Actual residential address: 1429A, 35B, Chandigarh
6. Name of the patient & his/her relation: Self
with govt. servant.(N.B._ in case of children state age also.)
7. Place at which patient fell ill: Chandigarh
8. Details of the amount claimed:
I. MEDICAL ATTENDANCE:_
(a) The name and desgn. of medical officer consulted -- Medical Officer at Civil
and the hospital or dispensary to which attached Dispensary, Sec 33, CHD
(b) The number and dates of consultations and fee One consultation on
paid for each consultation. 13.01.2022, fee paid NIL
(c) The number & dates of injections and the fee NIL
paid for each injection.
(d) Wheather consultation and/or injections were held Through consultation at
at the hospital/consulting room of the medical Dispensary
officer or at the residence of the patient.
II. Charges for pathological/bacteriological/radiological Rs. 971/-
or other similar tests undertaken during diagnosis indicating:
(a) The name of the hospital or laboratory where Dr. Shamsher Singh Memorial
tests were undertaken, and Radio-Diagnostic Centre,
Sector 16D, Chandigarh and
Chandigarh Clinical
Laboratories, Sector 16D,
Chandigarh
(b) Whether the tests were undertaken on the advice Yes, as per advice of
Of the authorised medical attendant, if so, Medical Officer at CD-33 on
a certificate to that effect should be attached. 13.01.2022 (slip enclosed)
III Cost of medicines purchased from the market: NIL
(list of medicines/cash memos & the essentiality certificate should be attached)
9. Total amount claimed. Rs 971/-
10.Less advance taken on NIL
11.Net amount claimed Rs.971/-

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the 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.

RECEIVED PAYMENT

Date:17.01.2022
Sign. Of Govt. Servant & office

S.NO NAME OF MEDICINE COST(Rs)

---NIL-------------
 Consultation Charges vide Healing Hospital Receipt Rs. 135.00
No. 43155 dated 21.03.2023 enclosed in original

S.NO NAME OF MEDICINES ** COST(Rs)

1 Cartigen DUO Tab 567.00
2 Palmiges 543.60
3 Zepclo Cap 621.00
4 Thumb Spica Splint UNI 229.50
Total 1,961.00
** Healing Pharmacy Invoice No. 11519 dated 22.03.2023 and No.
12075 dated 27.03.2023 enclosed in original
S.No. NAME OF TESTS && COST (Rs)
1 X-Ray (AP and Lateral) 288.00
2 Ultrasonic Therapy 900.00
3 Uric Acid 58.00
4 Anti Thyroid Peroxidase 345.00
Total 1,591.00
&& Healing Hospital Receipt No. 32990/22 dated 21.03.2023 and
Receipt No. 33099/22 dated 22.03.2023 enclosed in original.
Chandigarh Clinical Laboratories Reg. No. 150365 dated
25.03.2023 enclosed in original.

Total Amount Claimed Rs. 3,687/-

कार्यालयस्थानीयलेखापरीक्षाअधिकारी(वायुसेना)‘ब’
चंडीगढ़ – 160003.
Office of The Local Audit Officer (Air Force) ‘B’
Chandigarh – 160003
Email: laobafchandigarh.dad@hub.nic.in
Ph: 0172-2637642, AFNET : 2516-7540/7862
संख्या VJ/SAO/2023-24 दिनांक: 05.01.2024
सेवा में
रक्षा लेखा प्रधान नियंत्रक (वायु सेना)
नागपुर
विषय:- चिकित्सा दावे का प्रेषण
अधोहस्ताक्षरी से सम्बन्धित रू. 1,395/- का चिकित्सा दावा आपकी आवश्यक कार्यवाही
हेतु निम्नलिखित संलग्नकों के साथ भेजा जाता है:-
1. Form Med-97 दोप्रतियोंमें
2. AMA Dr V K Rampal द्वारादीगईसलाहपर्चीकीप्रतिलिपि
3. Preet Medical Hall Chandigarh की रसीद सं 3828 दिनांक 23.12.2023 एवं रसीद सं 3910 दिनांक
30.12.2023 की मूल प्रतियां
संलग्न: उपरोक्त
(विनीत जैन)
वरिष्ठ लेखा अधिकारी/98335890

कार्यालयस्थानीयलेखापरीक्षाअधिकारी(वायुसेना)‘ब’
चंडीगढ़ – 160003.
Office of The Local Audit Officer (Air Force) ‘B’
Chandigarh – 160003
Email: laobafchandigarh.dad@hub.nic.in
Ph: 0172-2637642, AFNET : 2516-7540/7862
संख्या VJ/SAO/2023-24 दिनांक: 05.01.2024
 कार्यालयस्थानीयलेखापरीक्षाअधिकारी(वायुसे
ना)
सेवा में ‘ब’ चंडीगढ़-160003.
Office of The Local Audit Officer (AF)
‘B’ Chandigarh-160003
Email: laobafchandigarh.dad@hub.nic.in
Ph: 0172-2637642, AFNET : 2516-7540/7862
रक्षा लेखा प्रधान नियंत्रक (वायु सेना)
नागपुर
विषय:- चिकित्सा दावे का प्रेषण
अधोहस्ताक्षरी से सम्बन्धित रू. 1,395/- का चिकित्सा दावा आपकी आवश्यक कार्यवाही
हेतु निम्नलिखित संलग्नकों के साथ भेजा जाता है:-
4. Form Med-97 दोप्रतियोंमें
5. AMA Dr V K Rampal द्वारादीगईसलाहपर्चीकीप्रतिलिपि
6. Preet Medical Hall Chandigarh की रसीद सं 3828 दिनांक 23.12.2023 एवं रसीद सं 3910 दिनांक
30.12.2023 की मूल प्रतियां
संलग्न: उपरोक्त
(विनीत जैन)
वरिष्ठ लेखा अधिकारी/98335890

संख्या: VJ/SAO/01/2024-25 दिनांक: 15.07.2024

सेवा में
रक्षा लेखा संयुक्त नियंत्रक (वायु सेना)
प्रशासन-वेतन अनुभाग
वायु सेना नगर, नागपुर

विषय: अधोहस्ताक्षरी से सम्बन्धित चिकित्सा दावों का प्रेषण।

कृपया अधोहस्ताक्षरी द्वारा भेजे गए पत्र दिनांक 12.04.2024 को देखें

जिसके अंतर्गत अधोहस्ताक्षरी से सम्बन्धित दो चिकित्सा दावे रू. 4,213/- एवं
रू. 550/- आवश्यक कार्रवाई हेतु भेजे गए थे। रू. 4,213/- के दावे में से मात्र रू.
1,135/- का ही भुगतान अधोहस्ताक्षरी को प्राप्त हुआ था। आपके कार्यालय के
सम्बन्धित अधिकारी से दूरभाष से सम्पर्क करने पर यह सूचित किया गया कि रू.
4,213/- के दावे में से रू. 3,078/- का दावा इस कारण से अस्वीकार कर दिया गया
क्योंकि दावे के साथ MAX Hospital के डॉक्टर की सलाह पर्ची जिसके अंतर्गत lab
tests लिखे गए हैं, की मूल प्रति संलग्न नहीं थी अपितु इसके स्थान पर पर्ची की
प्रतिलिपि संलग्न की गई थी। इस सम्बन्ध में सलाह पर्ची की मूल प्रति रू.
3,078/- की invoice/bill की प्रतिलिपि एवं पूरक दावे (supplementary claim) के साथ
आपके कार्यालय की आवश्यक कार्रवाई हेतु भेजी जाती है। चूंकि रू. 3,078/- की in-
voice/bill की मूल प्रति आपके कार्यालय द्वारा वापस नहीं की गई है अतएव इस बिल
की प्रतिलिपि संलग्न
की गई है।
इसके अतिरिक्त अधोहस्ताक्षरी से सम्बन्धित दो अन्य चिकित्सा दावे
रू. 1,188/- एवं रू. 350/- संलग्न कागजातों के साथ आपके कार्यालय की आवश्यक
कार्रवाई हेतु भेजे जाते हैं। रू. 1,188/- के दावे के सम्बन्ध में यह प्रस्तुत
किया जाता है कि MAX Hospital के डॉक्टर ने दिनांक 06.04.2024 को lab tests लिखते
हुए यह सलाह दी थी कि अगले विजिट पर इन lab tests को कराकर दिखाना है, तदनुसार इन
tests को CGHS द्वारा दिनांक 15.05.2024 अनुमोदन के बाद कराया गया।
संलग्न: उपरोक्त
 कार्यालय स्थानीय लेखा परीक्षा अधिकारी (वायु
सेना)
‘ब’ चंडीगढ़-160003.
Office of The Local Audit Officer (AF)
‘B’ Chandigarh-160003
Email: laobafchandigarh.dad@hub.nic.in
Ph: 0172-2637642, AFNET : 2516-7540/7862

(विनीत जैन)
वरिष्ठ लेखा
अधिकारी

संख्या: VJ/SAO/01/2024-25 दिनांक: 26.07.2024

सेवा में
रक्षा लेखा संयुक्त नियंत्रक (वायु सेना)
प्रशासन-वेतन अनुभाग
वायु सेना नगर, नागपुर

विषय: अधोहस्ताक्षरी से सम्बन्धित चिकित्सा दावे से कटौती।

संदर्भ:- समसंख्यक पत्र दिनांक 15.07.2024

कृपया अधोहस्ताक्षरी द्वारा भेजे गए पत्र दिनांक 15.07.2024 को देखें

जिसके अंतर्गत अधोहस्ताक्षरी से सम्बन्धित तीन चिकित्सा दावों में से एक
दावा रू. 3,078/- का था जिसमें से अधोहस्ताक्षरी को रू. 2,498/- का भुगतान
प्राप्त हुआ है एवं रू. 580/- की कटौती कर दी गई है जबकि empanelled अस्पताल से
कराए जाने वाले सभी परीक्षण डॉक्टर द्वारा लिखे गए हैं एवं केन्द्रीय
सरकारी स्वास्थ्य योजना के चिकित्सा अधिकारी द्वारा स्वीकृत भी किए गए
हैं। कृपया रू. 580/- की कटौती का विवरण अधोहस्ताक्षरी को सूचनार्थ प्रेषित
करें।

(विनीत जैन)
वरिष्ठ लेखा
अधिकारी

संख्या: VJ/SAO/01/2024-25 दिनांक: 11.03.2025

सेवा में
रक्षा लेखा संयुक्त नियंत्रक (वायु सेना)
प्रशासन-वेतन अनुभाग
वायु सेना नगर, नागपुर

विषय: अधोहस्ताक्षरी से सम्बन्धित चिकित्सा दावों का प्रेषण ।

अधोहस्ताक्षरी से सम्बन्धित तीन चिकित्सा दावे

रू.2,658/-, रू 761/- एवं रू.2,233/- आवश्यक कार्रवाई हेतु भेजे जाते
हैं l
संलग्न:- उपरोक्त

(विनीत जैन)
वरिष्ठ लेखा
अधिकारी
No: VJ/AO/2023-24
Office of the PCDA (WC)
Chandigarh
Dated: 17.07.2023
To
The Officer-in-charge
AN-VI, local.

SUB:- Forwarding of Medical Reimbursement Claim.

Medical Reimbursement Claim amounting to Rs. (-)11,723/- in respect of

the undersigned is forwarded herewith for further necessary action please. It
is submitted that amount of Rs. 11,723/- has been deposited by MAX Hospital to
the saving bank account of the undersigned. As such, it is requested that the
amount of Rs. 11,723/- may please be deducted from the pay and allowances of
the undersigned for the month of July 2023.

Encls: As stated.
(VINIT JAIN)
AO (Legal Cell)
 No. VJ/AO/2023-24
Office of the PCDA (WC)
Chandigarh
Dated: 17.07.2023
To
The Officer-in-charge
AN-I, local.

SUB:- Forwarding of Application in respect of undersigned.

An application regarding grant of commutted leave in respect

of the undersigned is forwarded herewith for further necessary action
please.

Encls: As stated.
(VINIT JAIN)
AO (Legal Cell)

No. VJ/AO/2023-24
Office of the PCDA (WC)
Chandigarh
Dated: 17.07.2023
To
The Officer-in-charge
AN-I, local.

SUB:- Forwarding of Application in respect of undersigned.

An application regarding grant of commutted leave in respect

of the undersigned is forwarded herewith for further necessary action
please.

Encls: As stated.
(VINIT JAIN)
AO (Legal Cell)
To
The PCDA (WC)
Chandigarh
(Through Proper Channel)

SUB:- Application regarding request for grant of Commutted

Leave.

Respected Sir
With due respect, I may submit that I was on pre-sanc-
tioned earned leave of five days with effect from 10.07.2023 to
14.07.2023. However, I fell ill in the morning of 13.07.2023 and
consulted Dr. D. S. Lamba, AMA, Phase 7, Mohali. As I was diag-
nosed with Viral Fever, AMA advised me to take bed rest for two
days (Medical Certificate dated 13.07.2023 is enclosed in origi-
nal). On further examination, he declared me fit to resume duty
on 14.07.2023 (AN) (Fitness Certificate dated 14.07.2023 is en-
closed in original).
I, therefore, request your goodself to cancel EL granted
of two days with effect from 13.07.2023 to 14.07.2023 and grant
Commutted Leave for the same period.
I shall be highly obliged to you for this act of kind-
ness.

Dated: 17.07.2023
Yours sincerely

(VINIT JAIN)
AO (Legal Cell)
Office of the PCDA (WC)
Chandigarh
 In lieu of MED.97
FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION
WITH MEDICAL ATTENDENCE AND/OR TREATMENT OF CENTRAL GOVT. SERVANTS AND THEIR FAMILIES.
N.B.:_ Separate form should be used for each patient.
1. Name and desgn. ofgovt.servant (in block letters): VINIT JAIN, AO/8335890
2. Office in which employed: PCDA (WC) Chandigarh
3. Pay of the govt. servant as defined in fundamental rules and
any other emoluments which should be shown separately: Rs. 80,200/- in Level 9
4. Place of duty : Chandigarh
5. Actual residential address: 532, Western Towers
Sector 126, Kharar
6. Name of the patient & his/her relation: Priya Jain, Wife
with govt. servant.(N.B._ in case of children state age also.)
7. Place at which patient fell ill: Chandigarh
8. Details of the amount claimed:
I. MEDICAL ATTENDANCE:_

(a) The name and desgn. of medical officer consulted -- Civil Dispensary Sec 8
and the hospital or dispensary to which attached Chandigarh
(b) The number and dates of consultations and fee One consultation on
paid for each consultation. 03.06.2023
(c) The number & dates of injections and the fee
paid for each injection.
(d) Whether consultation and/or injections were held At the Dispensary
at the hospital/consulting room of the medical
officer or at the residence of the patient.
II. Charges for pathological/bacteriological/radiological NIL
or other similar tests undertaken during diagnosis indicating:
(a) The name of the hospital or laboratory where
tests were undertaken, and
(b) Whether the tests were undertaken on the advice
of the authorised medical attendant, if so,
a certificate to that effect should be attached.
III Cost of medicines purchased from the market: 124/-
(list of medicines/cash memos & the essentiality certificate should be attached)
9. Total amount claimed. Rs 124/-
10.Less advance taken on NIL
11.Net amount claimed Rs 124/-

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the 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.

RECEIVED PAYMENT

Date: 24.07.2023
(VINIT JAIN)
AO (Legal Cell)
Office of PCDA (WC) Chandigarh
S.No NAME OF MEDICINES COST(Rs) S.No NAME OF MEDICINES COST(Rs)
1 KanchnarGuggulu 124.00
Total 124.00
 In lieu of MED.97
FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURED IN CONNECTION WITH
MEDICAL ATTENDENCE AND/OR TREATMENT OF CENTRAL GOVT. SERVANTS AND THEIR FAMILIES.
N.B.:_ Separate form should be used for each patient.
1. Name and desgn. ofgovt.servant (in block letters): VINIT JAIN, AO/8335890
2. Office in which employed: PCDA (WC) Chandigarh
3. Pay of the govt. servant as defined in fundamental rules and
any other emoluments which should be shown separately: Rs. 80,200/- in Level 9
4. Place of duty : Chandigarh
5. Actual residential address: 532, Western Towers
Sector 126, Kharar
6. Name of the patient & his/her relation: Self
with govt. servant.(N.B._ in case of children state age also.)
7. Place at which patient fell ill: Chandigarh
8. Details of the amount claimed:
I. MEDICAL ATTENDANCE:_

(a) The name and desgn. of medical officer consulted -- Civil Dispensary, Sector 8
and the hospital or dispensary to which attached Chandigarh
(b) The number and dates of consultations and fee Consultation on 07.07.2023
paid for each consultation. fee paid NIL
(c) The number & dates of injections and the fee NIL
paid for each injection.
(d) Whether consultation and/or injections were held At the Dispensary
at the hospital/consulting room of the medical
officer or at the residence of the patient.
II. Charges for pathological/bacteriological/radiological NIL
or other similar tests undertaken during diagnosis indicating:
(a) The name of the hospital or laboratory where
tests were undertaken, and
(b) Whether the tests were undertaken on the advice
Of the authorised medical attendant, if so,
a certificate to that effect should be attached.
III Cost of medicines purchased from the market: 809/-
(list of medicines/cash memos & the essentiality certificate should be attached)
9. Total amount claimed. Rs 809/-
10.Less advance taken on NIL
11.Net amount claimed Rs 809/-

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the 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.

RECEIVED PAYMENT

Dated: 24.07.2023
(VINIT JAIN)
AO (Legal Cell)
Office of PCDA (WC) Chandigarh

S.NO NAME OF MEDICINES COST(Rs)

1 Telmisartan 40 222.00
2 Atorvastatin 20 315.00
3 Pilofenac SD 99.00
4 RasnadiGuggulu 173.00
Total 809.00
To
The JCDA (AF)
Nagpur
(Through Proper Channel)

SUB:- Request for grant of Commutted Leave.

Respected Sir
With due respect, I may submit that I was not feeling
well on 02.08.2023 and accordingly, had submitted application
dated 02.08.2023 for grant of one day casual leave for your kid
consideration. However, during examination by Dr D S Lamba, AMA,
I was diagnosed with fever (low body temperature) and AMA ad-
vised me for rest of one day. On the same day, when I was re-ex-
amined in the evening, AMA declared me fit to join duty with ef-
fect from 03.08.2023 (Morning). Prescription slip issued by AMA
is enclosed.
I kindly request your goodself to cancel my casual
leave, if sanctioned, and grant me one day Commutted Leave for
02.08.2023.
I shall be highly obliged to you for this act of kind-
ness.

Dated: 03.08.2023
Yours sincerely

(VINIT JAIN)
LAO (AF) ‘B’
Chandigarh
 No. VJ/AO/2023-24
Office of the PCDA (WC)
Chandigarh
Dated: 30.06.2023
To
The Officer-in-charge
AN-VI, local.

SUB:- Forwarding of Application in respect of undersigned.

An application regarding grant of permission to get treatment

in CGHS empanelled Hospital as and indoor patient and grant of Medical
Advance in respect of the undersigned is forwarded herewith for fur-
ther necessary action please.

Encls: (i) Application dated 30.06.2023

(ii) Prescription slip from Shri V.K. Rampal, AMA
(iii) Prescription slip from Dr. SeemaWadhwa, MD
(iv) Inpatient Estimate dated 24.06.2023
(v) Bank Account particulars of MAX Hospital

(VINIT JAIN)
AO (Legal Cell)

No. VJ/AO/2023-24
Office of the PCDA (WC)
Chandigarh
Dated: 30.06.2023
To
The Officer-in-charge
AN-VI, local.

SUB:- Forwarding of Application in respect of undersigned.

An application regarding grant of permission to get treatment

in CGHS empanelled Hospital as and indoor patient and grant of Medical
Advance in respect of the undersigned is forwarded herewith for fur-
ther necessary action please.

Encls: (i) Application dated 30.06.2023

(ii) Prescription slip from Shri V.K. Rampal, AMA
(iii) Prescription slip from Dr. SeemaWadhwa, MD
(iv) Inpatient Estimate dated 24.06.2023
(v) Bank Account particulars of MAX Hospital

(VINIT JAIN)
AO (Legal Cell)
 No. VJ/AO/2023-24
Office of the PCDA (WC)
Chandigarh
Dated: 03.07.2023
To
The Officer-in-charge
AN-XI, local.

SUB:- Contingent Bill on account of purchase of newspapers.

Contingent Bill amounting to Rs. 3,000/- (Rs. Three Thousand

only) for reimbursement of the cost of newspapers in respect of under-
signed is forwarded herewith alongwith its enclosures for further
necessary action please.
Encls: As stated.

(VINIT JAIN)
AO (Legal Cell)

No. VJ/AO/2023-24
Office of the PCDA (WC)
Chandigarh
Dated: 03.07.2023
To
The Officer-in-charge
AN-XI, local.

SUB:- Contingent Bill on account of purchase of newspapers.

Contingent Bill amounting to Rs. 3,000/- (Rs. Three Thousand

only) for reimbursement of the cost of newspapers in respect of under-
signed is forwarded herewith alongwith its enclosures for further
necessary action please.
Encls: As stated.

(VINIT JAIN)
AO (Legal Cell)
 No. VJ/AO/2023-24
Office of the LAO (AF)
‘B’ Chandigarh
Dated: 03.08.2023
To
The JCDA (AF)
Nagpur

SUB:- Forwarding of Application.

An application dated 03.08.2023 in respect of the undersigned

regarding grant of Commutted Leave is forwarded herewith alongwith its
enclosures for furthernecessary action please.

Encls: As stated.

(VINIT JAIN)
LAO (AF) ‘B’

No. VJ/AO/2023-24
Office of the LAO (AF)
‘B’ Chandigarh
Dated: 03.08.2023
To
The JCDA (AF)
Nagpur

SUB:- Forwarding of Application.

An application dated 03.08.2023 in respect of the undersigned

regarding grant of Commutted Leave is forwarded herewith alongwith its
enclosures for further necessary action please.

Encls: As stated.

(VINIT JAIN)
LAO (AF) ‘B’
 In lieu of MED.97
FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION
WITH MEDICAL ATTENDANCE AND/OR TREATMENT OF CENTRAL GOVT. SERVANTS AND THEIR FAMILIES.
N.B.:_ Separate form should be used for each patient.
1. Name and desgn. ofgovt.servant (in block letters): VINIT JAIN, AO/98335890
2. Office in which employed: PCDA (WC) Chandigarh
3. Pay of the govt. servant as defined in fundamental rules Rs. 84,900/- in Level 10
4. Place of duty : Chandigarh
5. Actual residential address: 532, Western Towers
Sector 126, Kharar
6. Name of the patient & his/her relation: Kalash Jain, Son
with govt. servant.(N.B._ in case of children state age also.)
7. Place at which patient fell ill: Kharar
8. Details of the amount claimed:
I. MEDICAL ATTENDANCE:_

(a) The name and desgn. of medical officer consulted -- Dr. V K Rampal, AMA
and the hospital or dispensary to which attached
(b) The number and dates of consultations and fee Two consultations on
paid for each consultation. 23.12.2023 and 30.12.2023,
fee paid Rs. 700/-
(Rs. 350/- each)
(c) The number & dates of injections and the fee NIL
paid for each injection.
(d) Whether consultation and/or injections were held At the Dispensary
at the hospital/consulting room of the medical
officer or at the residence of the patient.
II. Charges for pathological/bacteriological/radiological NIL
or other similar tests undertaken during diagnosis indicating:
(a) The name of the hospital or laboratory where
tests were undertaken, and
(b) Whether the tests were undertaken on the advice
of the authorised medical attendant, if so,
a certificate to that effect should be attached.
III Cost of medicines purchased from the market: 695/-
(list of medicines/cash memos & the essentiality certificate should be attached)
9. Total amount claimed. Rs 1,395/-
10.Less advance taken on NIL
11.Net amount claimed Rs 1,395/-

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the 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.

RECEIVED PAYMENT

Date:05.01.2024
(VINIT JAIN)
LAO (AF) ‘B’ Chandigarh

S.NO NAME OF MEDICINES COST(Rs)

1 Seboclear Lotion 181.00
2 Moxikind CV 625 257.00
3 Moxikind CV 625 257.00
Total 695.00
 FORM – MRC (S)
(For serving employees)
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL REIMBURSEMENT CLAIM FORM

1. (a) Name of the Principal CGHS Card Holder : VINIT JAIN

(b) CGHS Beneficiary ID No. : 8419704
(c) Employee Code No. : 98335890
(d) Ward Entitlement – Pvt/Semi-Pvt/General : Private
(e) Full Address : H.No. 1212A, Sector 31B, Chandigarh
(f) Mobile No. and email address : 8054966094, vinitjani.dad@gov.in

2. (a) Patient’s Name : Priya Jain

(b) Patient’s CGHS Beneficiary ID No. : 8419706
(c) Relationship with the Principal CGHS : Wife
Card Holder

3. Name & address of the hospital/diagnostic : MAX Super Speciality Hospital, Mohali
Centrewhere treatment is taken or tests done

4. Whether the hospital/diagnostic/imaging centre : Yes

is empanelled under CGHS

5. Treatment for which reimbursement claimed

(a) OPD Treatment/Tests/investigations : Rs. 3,783/-

6. Whether treatment was taken in emergency : No

7. Whether prior permission was taken for treatment: Yes, from CGHS

8. Whether subscribing to a health/medical insurance: No

scheme. If yes, amount claimed/received

9. Details of medical advance taken, if any : No

10. Total amount claimed

(a) OPD Treatment : Rs. 700/- towards consultation charges
(b) Indoor Treatment : NIL
(c) Tests/Investigation : Rs. 3,083/- (Tests)

11. Name of the Bank: State Bank of India SB A/c No.: 30217511235
Branch MICR Code: 160002015 IFSC Code: SBIN0004703

DECLARATION
I hereby declare that the statements made in the application are true to the best of my knowledge and be-
lief and the person for whom medical expenses were incurred is wholly dependent on me. I am a CGHS
beneficiary and the CGHS card was valid at the time of treatment. I agree for the reimbursement as is ad-
missible under the rules.

Date: 30.06.2025
Place: Chandigarh
Signature of the Principal CGHS Card Holder
 FORM – MRC (S)
(For serving employees)
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL REIMBURSEMENT CLAIM FORM

1. (a) Name of the Principal CGHS Card Holder : VINIT JAIN

(b) CGHS Beneficiary ID No. : 8419704
(c) Employee Code No. : 98335890
(d) Ward Entitlement – Pvt/Semi-Pvt/General : Private
(e) Full Address : H.No. 1212A, Sector 31B, Chandigarh
(f) Mobile No. and email address : 8054966094, vinitjani.dad@gov.in

2. (a) Patient’s Name : Vinit Jain

(b) Patient’s CGHS Beneficiary ID No. : 8419704
(c) Relationship with the Principal CGHS : Self
Card Holder

3. Name & address of the hospital/diagnostic : Mukat Hospital & Heart Institute,
centre where treatment is taken or tests done Sector 34A, Chandigarh

4. Whether the hospital/diagnostic/imaging centre : Yes

is empanelled under CGHS

5. Treatment for which reimbursement claimed

(a) OPD Treatment/Tests/investigations : Rs. 350/-
(b) Indoor treatment : NIL

6. Whether treatment was taken in emergency : No

7. Whether prior permission was taken for treatment: Yes, from CGHS

8. Whether subscribing to a health/medical insurance: No

scheme. If yes, amount claimed/received

9. Details of medical advance taken, if any : No

10. Total amount claimed

(a) OPD Treatment : Rs. 350/-
(b) Indoor Treatment : NIL
(c) Tests/Investigation : NIL

11. Name of the Bank: State Bank of India SB A/c No.: 30217511235
Branch MICR Code: 160002015 IFSC Code: SBIN0004703

DECLARATION
I hereby declare that the statements made in the application are true to the best of my knowledge and be-
lief and the person for whom medical expenses were incurred is wholly dependent on me. I am a CGHS
beneficiary and the CGHS card was valid at the time of treatment. I agree for the reimbursement as is ad-
missible under the rules.

Date: 30.06.2025
Place: Chandigarh
Signature of the Principal CGHS Card Holder
 FORM – MRC (S)
(For serving employees)
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL REIMBURSEMENT CLAIM FORM

1. (a) Name of the Principal CGHS Card Holder : VINIT JAIN

(b) CGHS Beneficiary ID No. : 8419704
(c) Employee Code No. : 98335890
(d) Ward Entitlement – Pvt/Semi-Pvt/General : Private
(e) Full Address : H.No. 1212A, Sector 31B, Chandigarh
(f) Mobile No. and email address : 8054966094, vinitjani.dad@gov.in

2. (a) Patient’s Name : Vinit Jain

(b) Patient’s CGHS Beneficiary ID No. : 8419704
(c) Relationship with the Principal CGHS : Self
Card Holder

3. Name & address of the hospital/diagnostic : Grewal Eye Institute, Sector 9, Chandigarh
Centre where treatment is taken or tests done

4. Whether the hospital/diagnostic/imaging centre : Yes

is empanelled under CGHS

5. Treatment for which reimbursement claimed

(a) OPD Treatment/Tests/investigations : Rs. 761/-
(b) Indoor treatment : NIL

6. Whether treatment was taken in emergency : No

7. Whether prior permission was taken for treatment: Yes, from CGHS

8. Whether subscribing to a health/medical insurance: No

scheme. If yes, amount claimed/received

9. Details of medical advance taken, if any : No

10. Total amount claimed

(a) OPD Treatment : Rs. 350/-
(b) Indoor Treatment : NIL
(c) Tests/Investigation : Rs. 411/-

11. Name of the Bank: State Bank of India SB A/c No.: 30217511235

Branch MICR Code: 160002015 IFSC Code: SBIN0004703

DECLARATION
I hereby declare that the statements made in the application are true to the best of my knowledge and be-
lief and the person for whom medical expenses were incurred is wholly dependent on me. I am a CGHS
beneficiary and the CGHS card was valid at the time of treatment. I agree for the reimbursement as is ad-
missible under the rules.
Date: 11.03.2025
Place: Chandigarh
Signature of the Principal CGHS Card Holder
 कार्यालय स्थानीय लेखा परीक्षा
अधिकारी (वायु सेना)
‘ब’ चंडीगढ़ – 160003.
Office of The Local Audit Officer (Air Force)
‘B’ Chandigarh – 160003
Email: laobafchandigarh.dad@hub.nic.in
Ph: 0172-2637642, AFNET : 2516-7540/7862
सं. VJ/SAO/01/2025-26 दिनांक: 17.06.2025

सेवा में
प्रभारी अधिकारी
प्रशासन-वेतन अनुभाग
कार्यालय रक्षा लेखा संयुक्त नियंत्रक (वायु सेना)
वायु सेना नगर, नागपुर-440007

विषय:- चिकित्सा दावे का भुगतान

सन्दर्भ:- आपके कार्यालय का पत्रांक प्रशा-वेतन/375/चि.दा./एल.ए.ओ. दिनांक
16.04.2025

अधोहस्ताक्षरी से सम्बन्धित तीन चिकित्सा दावे रू. 2,658/-, रू. 761/- एवं
रू. 2,233/- अधोहस्ताक्षरी के दिनांक 11.03.2025 के पत्र के माध्यम से आपके कार्यालय
को भुगतान हेतु भेजे गए थे l संदर्भाधीन पत्र के माध्यम से सूचित किया गया है कि
इन दावों को क्रमश: रू. 1,447/-, रू. 350/- एवं रू. 2,233/- के लिए 03/2025 की DV संख्या
क्रमश: 30, 31 एवं 32 के माध्यम से पास किया गया l इस प्रकार दो दावों रू. 2,658/- में
से रू. 1,211/- की एवं रू. 761/- में से रू. 411/- की कटौती इस कारण से की गयी है कि आवश्यक
जांच के लिए CGHS अथवा सरकारी अस्पताल से रेफरेंस नहीं लिया गया है l
इस सम्बन्ध में यह प्रस्तुत किया जाता है कि रू. 761/- के दावे में
अधोहस्ताक्षरी की आँखों से सम्बन्धित विभिन्न चिकित्सीय जांच (Medical Tests
viz. Refraction, Indirect Ophthalmoscopy, Non-Contact tonometry and Fundus
Photo Test) जिनका CGHS Rate List के अनुसार कुल मूल्य रू. 411/- (Consultation के
अतिरिक्त) है, सम्मिलित हैं जो कि Eidon Procedure के अन्तर्गत आती हैं जिसे Pre-
scription Slip (मूल प्रति संलग्न जो कि मूल दावे के साथ संलग्न नहीं की गयी थी) में
नीचे की ओर लिखा गया है l चूँकि सभी जांच अलग अलग रूप से पर्ची पर नहीं लिखी हैं,
अधोहस्ताक्षरी की प्रार्थना पर जांच करते समय चिकित्सक के निर्देश पर उनके
सहायक ने सभी जांचों (Tests) को पर्ची पर हस्तलिखित कर दिया था एवं यह भी बताया था
कि ये सभी जांच Eidon Procedure का ही हिस्सा हैं l
इसी प्रकार रू. 2,658/- के दावे में की गयी कटौती रू. 1,211/- के सम्बन्ध
में स्पष्टीकरण निम्न प्रकार है:-
इस दावे में अधोहस्ताक्षरी की पत्नी की Grewal Eye Institute Pvt Ltd से
प्राप्त चिकित्सा MAX Hospital में चिकित्सक के द्वारा दिनांक 11.11.2024 को
लिखी गयी है (ECG/FUNDUS) जिसमें FUNDUS आँखों से सम्बन्धित परीक्षा है एवं
जिसका मूल्य रू. 761/- (Consultation के साथ) है l MAX Hospital में दिनांक
11.11.2024 को इलाज CGHS से दिनांक 07.11.2024 को रेफर करवाकर लिया गया है l इस
दावे में भी ऊपर वर्णित सभी जांच सम्मिलित हैं जो कि Eidon Procedure के
अन्तर्गत आती हैं जिसे Prescription Slip (मूल प्रति संलग्न जो कि मूल दावे के साथ
संलग्न नहीं की गयी थी) में नीचे की ओर लिखा गया है l इसके साथ ही रू. 100/- मूल्य
की ECG जांच MAX Hospital के द्वारा दिनांक 11.11.2024 लिखे जाने पर की गयी है
एवं दिनांक 17.02.2025 को रू. 350/- की consultation MAX Hospital से ली गयी है l इन
सभी का कुल मूल्य रू. 1,211/- आता है जिसकी कटौती कर ली गयी है l

(VINIT JAIN)
AO (Legal Cell)