---IN pursuance of the provisions of clause (3) of Article 348 of the Constitution, the Governor is pleased to order thepublication of the following English translation of notification no. 474N-6-14-1082/87 dated March 04 ,2014

GOVERNMENT OF UTTAR PRADESHMEDICAL SECTION-6

NOTIFICA TIONMiscellaneous

No. 474/ V-6-14-1082/87Dated Lucknow, March 04 ,2014

IN exercise of the powers conferred by the proviso to Article 309 of the Constitution, the Governor is pleased to make thefollowing rules with a view to amending the Uttar Pradesh Government Servants (Medical Attendance) Rules, 20 II:

THE UTTAR PRADESH GOVERNMENT SERVANTS (MEDICAL ATTENDANCE) (FIRSTAMENDMENT) RULES, 2014

Short title andcommencement

1. (1) These rules may be called the Uttar Pradesh Government Servants (Medical Attendance) (FirstAmendment) Rules, 2014

(2) They shall come into force at once.2.Amendment of

rule 3In the Uttar Pradesh Government Servants (Medical Attendance) Rules, 20 II, hereinafter referred

to as the said rules, in rule 3, for existing clauses(t) and (i) set out in column Ibelow, theclauses as set out in column 2 shall be substituted, namely:-

Column-IExisting clauses

"family" means :-i. Husband or wife as the case may

be, of the member of the service;and

ii. The parents, children, step-children,unmarried, divorced/separated daughter,unmarried/divorced/separated sisters, minorbrother(s), step mother.

(t)

Column-2clauses as hereby substituted

(t) "family" means :-i. Husband or wife as the case may be, of

the member of the service; andii. The parents, children, step-children,unmarried/ divorced/separated daughter,unmarried/divorced/separated sisters, minorbrother(s) and step mother; who are whollydependent on the Government Servant and arenormally residing with the Government Servant.

Note 1- Such members of a family will be consideredwholly dependent whose income from all sourcesdoes not exceed the sum of Rs. 3,500/- and the D.A.admissible on the basic pension of Rs.3500/- permonth at the time of the commencement of thetreatment.

Note 2- The age limit for the dependents would be asfollows:

(1) Son - Till the ti~ he is employed orattaining the age of 25 years or till he ismarried, whichever is earlier.

(2) Daughter - Till the time she is employed orshe is married, whichever is earlier.

(3) Son who is suffering from permanent mentalor physical disability - Till lifetime.

(4) Dependent and divorced/separated fromhusband/widow daughters and dependentunmarried/divorced/separated fromhusband/widow sisters - Till lifetime.

(5) Minor brothers - Till he attains maiority

/(i) "Government Hospital" means

a hospital run either by StateGovernment or CentralGovernment or associated toany Government MedicalCollege;

(I) "Government Hospital" means aHospital run either by State Governmentor Central Government or associated toany Government Medical College;"Authorized Contracted Hospitals"means such hospitals which arecontracted by the State Government toprovide treatment at par with the rates ofthe CGHS (Centralised GovernmentHospital Services);

(i)

(ii)

3. In the said rules, for existing rule 4 setsubstituted, namely :-

out in colum-I below, the rule as set out in column-2 shall beSubstitution ofrule 4

Column-2Rule as hereby substituted

4. All beneficiaries shall be entitled to freemedical attendance and treatment InGovernment Hospital or Medical Collegeor Authorised Contracted Hospitals.Ordinarily, this facility shall be provided atthe place of residence or posting of thebeneficiary. Registration fee and otherprescribed fees for medical attendance andtreatment shall be reimbursed fully by theGovernment. Ambulance shall also beprovided free of charge in urgent/emergentcases, ifthe circumstances so require.

Column-IExisting rule

4. All beneficiaries shall be entitled to freemedical attendance and treatment in GovernmentHospital or medical college. Ordinarily, thisfacility shall be provided at the place ofresidence or posting of the beneficiary.Registration fee and other prescribed fees formedical attendance and treatment shall bereimbursed fully by the Government. Ambulanceshall also be provided free of charge Inurgent/emergent cases, if the circumstances sorequire.

Entitlement offree medicalservices

Entitlement offreemedicalservi-ces

4. In the said rules, in rule 6 for existing sub rule (a) set out in column-I below, the sub rule as set out incolumn-2 shall be substituted, namely :-

Amendment ofrule 6

Column-IExisting sub rule

(a) Free medical treatment shall be available to abeneficiary only when he/she produces the proofof hislher identity through a numbered healthcard issued under the signature and seal of theHead of Office on proforma given in Appendix-A. The photograph on the card shall be sostamped with official seal that it covers thephotographs and the card partially:

Provided that for a pensioner thedesignation, place of posting, basic pay and payscale shall relate to hislher last posting beforehislher retirement/death but the health card willbe issued by the Head of the office of his/herserving department located at the place fromwhere he/she is drawing pension or residing.

Column-2Sub rule as hereby substituted

(a) Free medical treatment shall be available to abeneficiary only when he/she produces the proof ofhis/her identity through a numbered health card issuedunder the signature and seal of the Head of Office onproforma given in Appendix-A. The photograph onthe card shall be so stamped with official seal that itcovers the photographs and the card partially:

Provided that for a pensioner the designation,place of posting, basic pay and pay scale shall relateto hislher last posting before hislher retirement/deathbut the health card will be issued by the Head of theOffice of hislher serving department located at theplace from where he/she is drawing pension orresiding. -

In future the Government may stepwise issueU.P. Health Service Identity Card (Smart Card) inplace of Health Certificate.

/ Amendment ofrule 7

2

5. In the said rules, in rule 7, for existing sub rule (a) set out in column-l below, the sub rule as set out incolumn-2 shall be substituted, namely :-

Provided that last basic pay drawn bypensioner shall be taken as basic pay fordetermining entitlement. However, a pensionershall be entitled for services not inferior to theones that he/she has been getting just beforeretirement.

Provided further that in case a beneficiaryis provided better accommodation facilities thanthe actual entitlement on request, he/she shallhave to bear the additional expenses.

Rs. I9,000/- or Private/Specialabove VVardsAboveRs. I3,000/- andbelow Paying VVards

Rs.19,000/-Rs.13,000/- orbelow

General VVards3

Provided that last basic pay drawn bypensioner shall be taken as basic pay for determiningentitlement. However, a pensioner shall be entitled forservices not inferior to the ones that he/she has beengetting just before retirement.

Treatment InSGPGIIKGMU/Gover-nmentMedi-calColle-ges

Seri Basic PayVVardsfor which

-al beneficiary wouldNo- +Grade Pay be entitled

I Rs.19,000/- or Private/Specialabove VVardsAbove

2 Rs.13,000/- and Paying VVardsbelowRs.19,000/-

3Rs.13,OOO/- or

General Wardsbelow

Provided further that in case a beneficiary isprovided better accommodation facilities than theactual entitlement on request, he/she shall have tobear the additional expenses.

Note; For indoor treatment in Authorised ContractedHospitals the criteria for entitlement of ward would bebased on the limits of the Basic Pay + Grade Pay asapplicable to Government servants covered under theCGHS rates of Government of India in such hospitals.

Substitution ofrule 10

TreatmentSGPGI/CSMMU

6. In the said rules, for existing rule 10 set out in colum-I below, the rule as set out in column-2 shall besubstituted, namely :-

Column-IExisting rule

10. Beneficiary on payment may get treatment inSanjay Gandhi Post Graduate Institute ofMedical Sciences and Research (SGPGIMS),Lucknow, and Chhatrapti Shahuji MaharajMedical University (CSMMU), Lucknowwithout reference. The expenditure on medicalattendance or treatment shall be whollyreimbursable on submission of claim Inprescribed manner.

Column-2Rule as hereby substituted

10. Beneficiary on payment may gettreatment in Sanjay Gandhi Post GraduateInstitute of:. Medical Sciences andResearch (SGPGIMS), Lucknow,K.G.M.U., Lucknow and GovernmentMedical College without reference. Theexpenditure on medical attendance ortreatment shall be wholly reimbursable onsubmission of claim in prescribed manner.

In addition to above, the treatmentcan be obtained with reference againstpayment in the Authorised ContractedHospitals. The expenses incurred on

Substitution oflong heading ofPart-III

medical care or treatment under theprescribed rules will be fully reimbursableon submission of the claim.

7. In the said rules, after rule 10, for the existing long heading "PART-III TREATMENT INEMERGENCY ON TOUR AND SPECIALIZED TREATMENT", the long heading "PART-III-TREATMENT IN EMERGENCY AND ON TOUR AND SPECIALIZED TREATMENT" shall besubstituted.

Column-lExisting rule

11. A beneficiary is permitted to get treatment ina private hospital in urgent/emergent conditionwithin state or outside. The cost of treatmentshall be reimbursable at the rates of SanjayGandhi Post Graduate Institute of MedicalSciences and Research (SGPGIMS), Lucknow incase of treatment within the state or All IndiaInstitute of Medical Sciences, New Delhi fortreatment outside the state provided:(a)The treating doctor certifiesurgency/emergency.(b) The patient informs the Head of Office assoon as possible but not later than thirty daysfrom the date of the commencement oftreatment.(c) In case of emergency, the expenditure on airambulance shall also be admissible forreimbursement.

Substitution ofrule II

Treatment inUrgency/Emergency

8. In the said rules, for existing rule 11 set out in column-I below, the rule as set out in column-2 shall besubstituted, namely :-

the

TreatmentUrgency/Emerg-ency

Column-2Rule as hereby substituted

11. A beneficiary is permitted to gettreatment in a private hospital orAuthorised Contracted Hospitals inurgent/emergent condition or on tourwithin State or outside. The cost oftreatment shall be reimbursable at therates of Sanjay Gandhi Post GraduateInstitute of Medical Sciences andResearch (SGPGIMS), Lucknow in caseof treatment within the State or All IndiaInstitute of Medical Sciences, New Delhiin case of treatment outside the State andin case of treatment in AuthorisedContracted Hospitals, the cost oftreatment shall be reimbursable at therates ofC.G.H.S. provided:(a)The treating doctor certifies theurgency/emergency.(b) The patient or his relative informs theHead of Office as soon as possible butnot later than thirty days from the date ofthe commencement of treatment.(c) In case of emergency, the expenditureon air ambulance shall also be admissiblefor reimbursement.

Substitution ofrule 12

Treatment ontour

9. In the said rules, for existing rule 12 set out in column-l below, the rule as set out in column-2 shall besubstituted, namely :-

Column-lExisting rule

12. The Government Servants on official duty to Treatmentother states shall be entitled for medical onattendance and treatment in the Govenunent tourhospital of the concerned State and the actualexpenses incurred thereon shall be whollyreimbursable:

Provided that the expenditure incurred ontreatment in medical colleges, institutes orprivate hospitals shall be reimbursable at the rateof All India Institute of Medical Sciences(A.l.I.M.S).

Column-2Rule as hereby substituted

12. The Government Servants on officialduty or for personal work during tour toother states shall be entitled for medicalattendance and treatment In theGovernment hospital or authorizedcontracted hospital of the concernedState and the actual expenses incurredthereon shall be wholly reimbursable:

Provided that the expenditureincurred on treatment In medicalcolleges, institutes or private hospitalsout side the State shall be reimbursableat the rate of All India Institute of

lr------r--- __ .....-----.----~___::_:_____:__Medical Sciences (A. I.l.M.S) andtreatment In authorized contractedhospital shall be reimbursable at theCGHS rates.It is expected from the Governmentservants that they should obtain thetravel and health insurance policy whileon official tour to foreign country so thatin case of requirement they can get thebenefit of medical treatment under theinsurance policy during the foreign tour.The insurance premium on the travel andhealth insurance policy can bereimbursed in the TA bill along with theticket but under no circumstances anymedical reimbursement shall besanctioned by the State Governmentseparately. The cost of medical treatmentwould not be reimbursable on foreigntour for personal work.

Amendment ofrule 13

10. In the said rules, in rule 13 for existing sub rule (a) and (b) set out in column-l below, the sub rule asset out in column-2 shall be substituted, namely :-

Column-\Existing sub rules

(a) For the treatment of complicated and seriousailments for which medical facilities are notavailable at the Government hospitals orreferring institutions, the treating doctor notbelow the rank of Professor or Head of theDepartment of referring institution may refer thepatient to a private hospital or institutionrecognized by the State or Central Governmentfor treatment and medical attendance.

(b) The reimbursement of the expenditure ontreatment in such private hospital or institutionshall be limited to the actual expenditure or therates of S.G.P.G.I.M.S., Lucknow for treatmentwithin State or the rates of All India Institute ofMedical Sciences (A.I.I.M.S.), New Delhi fortreatment outside the State, whichever is less.

Column-2Sub rules as hereby substituted

(a) For the treatment of complicated and seriousailments for which medical facilities are not availableat the Government hospitals or referring institutions,the treating doctor not below the rank of Professor orHead of the Department of referring institution orChief Medical Superintendent of the GovernmentDistrict Hospital or Chief Medical Officer of theDistrict may refer the patient to a private hospital orinstitution recognized by the State or CentralGovernment for specialized treatment and medicalattendance.(b) The reimbursement of the expenditure ontreatment in such private hospital or institution shallbe limited on the actual expenditure or the rates ofS.G.P.G.I.M.S., Lucknow for treatment within Stateor the rates of All India Institute of Medical Sciences(A.l.I.M.S.), New Delhi for treatment outside theState, whichever is less.

The expenditure incurred on referral cases toauthorized contracted hospitals shall be reimbursed atthe CGHS rates.

Amendment ofrule 15

Amendment ofrule 19

I I. In the said rules, in rule 15 for existing sub rule (e) and (i) set out in column- I below, the sub rules asset out in column-2 shall be substituted, namely :-

Column-IExisting sub rules

(e) Another advance shall not be sanctioned underany circumstances unless the previous one hasbeen adjusted.

(i) If the treatment has not started after sanction ofthe medical advance, the refund of such advancehas to be made in three months and if the refund ofsuch advance is not made within a period of threemonths, the punitive interest shall also be imposedwhich will be calculated at the rate of interestprevailing on the date of sanction of medicaladvance.

Column-IExisting sub rule

(a) Competent authority for technical examination shallbe as follows:

Amount of claim(i)up to Rs.40,OOOI-

Competent authorityMedical Officer-in-chargelSuperintendent of treatingor referring Governmenthospitall GovernmentAurvedic, Unani andHomeopathy hospital.

(ii)Rs.40,OOOI- andabove

Superintendent-in-ChieflMedical Superintendent oftreating or referringGovernment hospitalICMO/District HomeopathicMedical Officer or RegionalAurvedic and Unani Officer.

(iii)For specializedtreatment in privatehospitals

By treating doctor not belowthe rank of the Professor orHead of the Department ofreferring institution asprovided in Rule 13 (a).

Column-2Sub rules as hereby substituted

(e) In case of continuous treatment of the disease,second advance may be sanctioned subject to thecondition that the earlier sanctioned advance isadjusted by presenting a partial claim, taking intoconsideration the specific conditions, on the adviceand recommendation of the attending doctor.

(i) If the treatment has not started after sanction ofthe medical advance, the refund of such advancehas to be made in three months and if the refund ofsuch advance is not made within a period of threemonths, the punitive interest shall also be imposedwhich will be 2.5% more than the normal rate ofinterest as applicable in Provident Fund.

(iii)For specializedtreatment in privatehospitals

12. In the said rules, in rule 19 for existing sub rule (a) set out in column-I below, the sub rule as set out incolumn-2 shall be substituted, namely :-

Column-2Sub rule as hereby substituted

(a) Competent authority for technical examination shall beas follows:

Amount of claim(i) up toRs.50,OOOI-

Competent authorityMedical Officer-in-chargelSuperintendent of treating orreferring Government hospitallGovernment Aurvedic, Unaniand Homeopathy hospital

(ii)Rs.50,OO 1/- andabove

Superintendent-in-ChieflMedical Superintendent oftreating or referringGovernment hospitallCMO!District Homeopathic MedicalOfficer or Regional Aurvedicand Unani Officer

By treating doctor not belowthe rank of the MedicalSuperintendent IChief MedicalSuperintendent IChief MedicalOfficer of the District orProfessor or Head of theDepartment of referringinstitution as provided in Rule13 (a)

/

/ Substitution ofrule 20

Sanctioningauthority

13. In the said rules, for existing rule 20 set out in colum-l below, the rule as set out in column-2 shall be substituted,namely:-

Column-IExisting Rule

20. Authorities competent to sanction the Sancti-reimbursement claim for treatment shall be as follows: oningrl(••ia)~jfi.;;.or;..G..;..;.o_ve.;.;rn..;.;.;.;.m.;.;e_n_t.;;.Se.;.;rv....,an~t..: -4 autho-~Arn~o~u~n~t~o~f~c~la_im~~~~San~c~ti~o~n~in~~a~u_th.;.;o.;;.ri~·w~_--irity

Up to Rs.I,OO,OOO/- Head of Office

Above Rs.2,50,OOO/-up to Rs.5,OO,OOO/-

Above Rs.I,OO,OOO/- Head of Departmentup to Rs.2,50,OOO/-

Above Rs.5,00,000/-

AdministrativeDepartmentGovernment

in the

After recommendationfrom Medical and HealthDepartment and piorapproval of the FinanceDepartment,AdministrativeDepartmentGovernment.

in the

Amount of claim

(b) For retired Government Servants:

Sanctioning authorityUp to Rs.l,OO,OOO/-

Above Rs.I,OO,OOO/-up to Rs.5,00,OOO/-

Above Rs.5,OO,OOO/-

After recommendation ofthe competent technicalexamination officer, theHead of OfficeAfter recommendation ofthe competent technicalexamination officer and onsubmission by theconcerned Head of Officethe District Magistrate.After recommendation ofthe competent technicalexamination officer and onsubmission by theconcerned Head of Officethrough proper channel tothe AdministrativeDepartment afterrecommendation fromMedical and HealthDepartment and priorapproval of the FinanceDepartment, theAdministrativeDepartment.

Column-2Rule as hereby substituted

20. Authorities competent to sanction thereimbursement claim for treatment shall be asfollows:

For working/retired Government ServantAmount of claim Sanctionin~ authorityUp to Rs.2,00,000/- Head of Office

From Rs.5,OO,OOO/-up to Rs.1 0,00,000/-

Above Rs.2,00,000/- Head of Departmentup to Rs.5,00,OOO/-

Administrative Departin the Government

Above Rs.l 0,00,0001 After recommen-dation from MedicalHealth Departmentprior approval ofFinance Departme-nt,AdministrativeDepartment inGovernment.

/Amendment of 14. In the said rules, in rule 22 for existing sub rule (c) and (d) set out in column-1 below, the sub rule as setrule 22 out in column-2 shall be substituted, namely :-

Co1umn-1 Column-2Existing sub rule Sub rule as hereby substituted

(c) The patient and the attendant if any, shall be (c) The patient and the attendant if any, shall beentitled to travelling allowance for such journey entitled to travelling allowance for such journey fromfrom hislher residence to the place of the hislher residence to the place of the treatment andtreatment and back by shortest rail route to the back by shortest rail route to the extent of entitlementextent of entitlement of his official journey, but of his official journey. However, no daily allowanceno daily allowance on journey by aero plane would be permissible.shall be admissible even if the beneficiary is orwas entitled for the same.(d) In case of critical illness, the journey by aero (d) In case of critical illness, the journey by aero-plane may be allowed by the Government on the plane may be allowed by the Government on thewritten recommendation of the authorized written recommendation of the authorized medicalmedical attendant. attendant. However, no daily allowance would be

permissible on such journey.Substitution of Appendix - '115. In the said rules, for the existing Appendix - "C" set out in column below, the Appendix

as set out in column - 2 shall be substituted, namely»

Column-1Existing AppendixAPPENDIX - "C"

(SEE PART - V, RULE 16 and 18)

Name of Head of Office

Subject: Reimbursement of expenditure done on medical treatment

Sir,I /My family members Name .

took treatment at (hospital name) for (diseasename) from (date) to My health card no I am submittingthe claim with following documents for reimbursement: .

1. Essentiality Certificate duly signed/countersigned by treating doctors/Superintendent of the Hospital.2. Original Cash memo. Bills, Vouchers duly signed and verified by treating doctor.3. It is certified that the above named family member is wholly dependent on me.

Kindly do the needful for reimbursement of my claim after adjusting the advance of Rs sanctioned for mytreatment vide letter no dated of . .

Dated .

Name of OfficerlEmployee

Designation

Place of Posting

Column-2Appendix as hereby substituted

APPENDIX - "C"(SEE PART - V, RULE 16 and 18)

Name of Head of Office

Subject: Reimbursement of expenditure done on medical treatment

Sir,

I /My family members Name .

took treatment at (hospital name) for (disease

name) from (date) to My health card no I am submitting

the claim with following documents for reimbursement:

1. Essentiality Certificate duly signed/countersigned by treating doctors/Superintendent of the Hospital.

2. Original Cash memo. Bills, Vouchers duly signed and verified by treating doctor.

3. It is certified that the above named family member is wholly dependent on me and normally resides with

me.

Kindly do the needful for reimbursement of my claim after adjusting the advance of Rs sanctioned for my

treatment vide letter no dated of .

Dated .

Name of Officer/Employee

Designation

Place of Posting

B)' order,

Pravir KumarPrincipal Secretary

APPENDIX VIIIForm of Certigicates A and B

Certificate granted to Mrs.fMr./Miss .

......................................... wife/SonlDa ugh ter of Mr .

employed in the ...............................................................................................CERTIFICATE A

(To be completed in the cause of patients who are not admitted to hospitalfor treatment)

I Dr hereby certify(a) that I charged and received Rs for consultation on.....•...••.....•..............•...... (dates to be given) at my consulting room at theresidence of patient.(b) that I charged and received Rs.......•..•••...........• for administering.....••.•••.•.•.•••••.•..•.intra-muscular-injections on......•..........•.. sub-cutaneous atmy consulting room ..••••........•.........•...at the residence of the patient.

(c) that the injections administered were for immunising or prophy lacticpurposes. were not.

(d) that the patient has under treatment at hospital/ my consulting roomand the undermentioned medicines prescribed by me in this connectionwere essential for the recovery/ prevention of serious, deterioration in thecondition on the patient. The medicines are not stocked in the v•............................... v. for supply to private patient .(name of the hospital) and do not include propriatary preparations forwhich cheaper substances of equal therepeutic value are available norpreparations which are primarily/foods, toilets orNAME OF MEDICINES PRICE1.2.3.4.5.6.7.8.

(e) that the patient is/was suffering from ..•.........•............................. and is/was under my treatment from to .

(t) that the patient is/was not given prenatal or postnatal treatment.

-2-(g) that the X-ray, laboratory test, etc. for which on expenditure ofRs ........•............... was incurred were necassary and were undertaken onmy advice at .•..•..••••••.•••••.(Name of hospital or laboratory)

(h) that I referred the patiant to Dr ...........•.•....•.••..••••..•..•••.•.•••..........forspecialist consultation and that the necessary approval of the ............•..•............................................................................................... (Name of the Chief).............................................................................. as required under therules (Administrative Medical Officer of State.)

(i) that the patient did not required hospitalisation ....•••.•....•..•.•....required.

Dated .

Signature & Designation of theMedical Officer and hospitaldispensary to which attached.

N.B. : Certificates not applicable should be struck off.Certificates (a) is compulsory and must be filled my by the Medicalofficer in all cases.

COUNTERSIGNED

Medical Superinteandent.................................. Hospital

I certify that the patiant has been under treatment at the •....•..........•..••.....•............................................................... hospital and that the facilitiesprovided were the minimum which were essential for the patient'streatment.

Place:Dated:

Medical Superintendent..: Hospital

CERTIFICATEB(To be completed in the case of patients who are admitted to

hospital for treatement)

Certificate granted to Mrs./M r.fMiss .

......................................... wife/SonlDaughter of Mr ..•..•......••........•..........•••.•.•.

employed in the .

PART- A

(To be signed by the Medical Officer incharge of the case at the hospital)

1. I Dr hereby certify

(a) That the patient was admitted to hospital on my advice! advice of ..................................................................................................................................

(Name of Mdical Officer)

(b) That the patient has been under treatment at ...•...•...•.....•.••••••.........•.............................................................................................................. and that theundermentioned medicines prescribed by me in this connection wereessential for the recovery! prevention of serious, deterioration in thecondition on the patient.

2- The medicines are not stocked in the .•..•........•......•....•...•..•..•••........•..•.......•.•........•••..•.••...•....•for supply to private patients and do not includeproprietary preparations for which cheaper substances of equalthereapeutic value are available not preparations which are primarilyfods, toilets.ISL.No. I-N-A-M-E-O-F-M-E-n-IC-I-N-ES-------r-IP-R-I-C-E-----1.2.3.4.5.6.7.8.9.10.11.

-2-(e) that the patient is/was suffering from ..........•..................•.........•.. and is/was unde-r my treatment from to .

(f) that the patient is/was not given prenatal or postnatal treatment.

(g) that the X-ray, laboratory test, etc. for which on expenditure ofRs ........•.•............. was incurred were necassary and were undertaken onmy advice at ....••.............••(Name of hospital or laboratory)

(h) that I referred the patiant to Dr ........•...•..•.•.•...•...••......••......•........ forspecialist consultation and that the necessary approval of the ...••.......•.................................................................................................. (Name of the Chief).............................................................................. as required under therules (Administrative Medical Officer of State.)

(i) that the patient did not required hospitalisation ....•.................. required.

Dated .

Signature & Designation of theMedical Officer and hospitaldispensary to which attached.

N.B. : Certificates not applicable should be struck off.Certificates (a) is compulsory and must be filled my by the Medicalofficer in all cases.

COUNTERSIGNED

Medical Superinteandent.................................. Hospital

I certify that the patiant has been under treatment at the .....•........••..••.•.•.................................................................. hospital and that the facilitiesprovided were the minimum which were essential for the patient'streatment.

Place:Dated:

Medical Superintendent.......................... Hospital