If any question arises as to whether any service is included in the medical altendancc or trcatment, it shall be rcfcrrcd to the Government and the decislon uí üu uuv thereon shall be final.
By order and in the name of Governor of Karnataka E.SHTVANANDA Under Secretary to Government (Admn-1) Law, Justice & Human Rights Dept.
FORM 'A Vide rule 6 (1)] Essentiality Certiffcate I certify that Shri/Smt..- . Judicial Offcer/member of the family of the judicial officer, has been under my treatment for ..- -.disease from .---to .. at the .---- hospital/ dispensary/my consulting room and that the under-mentioned medicines prescrlbed 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 ..
Patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparations which are primarily foods, toilets or disinfectants, Hospital/dispensary, for supply to Private Si. Name of the Medicines Bill No./Date Amount No.
Signature and Designation of Aulhorized Medical Allendanl Date:
Counter-signalure of Lhe Medical Omcer 146 FORM 'B See rule 6{2) APPLICATION FROM FOR CLAIMING REFUND OF MEDICAL EXPENSES
01. Name and destgnation of the Judictal Officer
02. Ofice in whlch cmployed
03. Salary
04. Place of duly 05 Full residentlal address
06. Name of the Patient and his/her Relationship of Judicial Officer 07 Place at which the patient fell ill.
08. Nature of illness and ils duralion
09. Details for lhe amnount clalned
10. Total amounl claimed
11. List of ernclosures DECLARATION TO BE SIGNED BY THE JUDICIAL OFFICER Ihereby declare that the stalements in this application are true to the best of my knowledge and belfel and Lhal the person for whom medical expenses were incurred is a member of my lamily as delined under the Kamataka Judicial Officers (Medical Attendancc) R1ules, 2009 and is wholly dependent on me.
Dale: SIGNATURE OF THE APPLICANT Place No:
Sanctiom is accordcd for the reimbursement of Medical charges amounting of Rs....Rupees only) incurred by the Applicant in connection with his/her Medical expenses and the cost of reimburserment being met out of the provisions made under the Head.
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