CEERTIFICATE

It is certified that Mr. Vijay Kumar Katyal son of Sh. Ram Dass Katyal employed in the office
DS Sub Division, PSEB, Dera Bassi has been under my treatment at Sir Ganga Ram
Hospital Marg Old Rajinder Nagar, New Delhi my consultation room & that the medicines
mentioned hereunder have been prescribed by me in this connection were absolutely
essential for the treatment of recovery/prevention of serious and deteriorated condition of
the patient. The decidines were not stocked in the Sir Ganga Ram Hospital Marg Old
Rajinder Nagar, New Delhi name of the propriority for which cheaper substituted of equal
value are available nor preparation which is primarily food/tonic value are available nor
preparation which is or disinfectent.

3.                  Certified that the medicines charges have no cheaper effective substitute.
4.                  Period of treatment from 27-1-2007 to 2-2-2007.
5.                  Certified that the medicines prescribed are not in the list of non-reimbursement
medicines particulars last revised in Govt. letter 170/1403/1581/RI/IRST-76/7706 dated 2-1-
1957.
6.                  Certified that the prices claimed is reasonable.
7.                  He was suffering from _____________________.

Sr. No. Name of medicines Indoor ticket Dt. of which Amount

No./Dt. on medicines
which actually
medicines purchased.
purchased/
prescribed.
1 PART-A HOSPITAL CHARGES 003482 27- 27-1-07
1-07
ROOM RENT 23100
BLOOD GAS ANALYSIS 3200
BED SIDE PROCEDURE SERVICES 760
CHARGES
DRESSING SET CHARGES 400
ECG 160
E.M.G. 1900
GLUCOMETRY CHARGES 2460
HEMATOLOGY LAB CHARGES 2980
I.C.U. CHARGES 18200
BIOCHEMISTRY LAB CHARGES 6260
MEDICINE FROM WARD (DETAIL 16433
ATTACHED)
MICROBIOLOGY LAB CHARGES 3500
MEDICINE FROM HOSP. PHARMACY 145580
ECHOCARDIOGRAM PORTABLE 3900
 VAT CHARGES 4% 314
VENTILATOR CHARGES 12250
X-RAY 3240
DOCTORS VISIT FEE 18900
POOL A/C PROCEDURE CHARGES 7600
TOTAL 271137
MEDICINE REFUNDED TO PHARMACY (-) 2709
GRAND TOTAL 268428

Signature & Designation

of authorized Medical attendant
1.                  Certified that my son/wife/daughter has no source of income of the own and is
actually residing with me and wholly depends upon me.
2.                  Certified that my basic pay is Rs.________________.
3.                  Certified that medicines have been actually purchased by me & full consumed
on the treatment of my ____________________.
4.                  Certified that the payment made by me in the Ist instance.
5.                  Certified that I am not claiming fixed medical allowance.

Signature of employee.
PART-B: MEDICINES
PURCHASED FROM BILL NO. MEDICINES QTY. RATE AMOUNT
SIR GANGA RAM HOSPITAL 167893 INJ IVIGLOB EX 5 3327.20 16636.00
PHARMACY (COUNTER -II) 27-1-07 NEWPAN INJ 2 53.00 106.00
MEZOLAM 1 ML 15 33.30 499.50
INJ PROPDFOL 50 ML 4 432.69 1730.76
VAT CHARGES 93.43
TOTAL-(1) 19065.69
SIR GANGA RAM HOSPITAL 465106 PANTOP INJ 2 51.97 103.94
PHARMACY GROUND 28-1-07 PROPOFOL 1% LIPURO 50 ML 2 432.69 865.38
FLOOR HEPALOCK INJ 3 6.95 20.85
DISPOSABLE SYRINGES 50 ML 2 25.96 51.92
DISPOSABLE SYRINGES 5 ML 5 4.61 23.05
I.V. SET (ROMSONS) 2 37.50 75.00
DEXTROSE 5% 500 ML VIAFLEX 4 61.00 244.00
NORMAL SALINE 500 ML VIAFLEX 3 61.00 183.00
MEDIFLON 20.22G 1 65.38 65.38
RINGER LACTATE 500 ML (ALBERD) 1 40.73 40.73
COTTON ROLL 250 GM 1 48.07 48.07
URO BAG 1 38.46 38.46
VAT CHARGES 70.39
TOTAL-(2) 1830.17
465390 INJ (CEFOP+SALTU) 2 GM 4 527.76 2111.04
28-1-07 ATEN 25 MG 14 1.54 21.56
NEZOLAM 1 ML 20 33.3 666.00
VAT CHARGES 111.88
TOTAL-(3) 2910.48
SIR GANGA RAM HOSPITAL 167986 INJ IVIGLOB EX 4 3327.20 13308.80
PHARMACY (COUNTER -II) 28-1-07 TOTAL-(4) 13308.80
168151 CLEXANE 60 MG 1 514.50 514.50
28-1-07 VAT CHARGES 20.58
TOTAL-(5) 535.08
168186 BAG SET FOR GRAVITY + `T` PC, 1 325.00 325.00
28-1-07 FRESENIUS
IMPACT ORAL PDR, 61 GMS 3 81.78 245.34
ALPRAX TAB .5 MG 2 2.33 4.66
VAT CHARGES 43.84
TOTAL-(6) 618.84
168079 INJ MAGNEX 20M 2 527.76 1055.52
28-1-07 GAMMA-I,V 5GM(H,NORM, 4 4015.77 16063.08
IMMUNOGLOBULIN)
PROPOFOL 1% LIPURO 20 ML 1 196.00 196.00
TAB BETACARD 25 MG 4 1.60 6.40
VAT CHARGES 50.30
TOTAL-(7) 17371.30
SIR GANGA RAM HOSPITAL 465629 RESOURCE POWDER 3 37.78 113.34
PHARMACY GROUND 29-1-07 COTTON ROLL 250 GM 1 48.07 48.07
FLOOR MICROPORE TAPE 3 INCH 1 89.90 89.90
DISPOSABLE SYRINGES 20 ML 2 15.38 30.76
DISPOSABLE 50 ML ROMOJET 2 28.85 57.70
NEEDLES FOR SYRINGE 5 1.68 8.40
VAT CHARGES 23.57
TOTAL-(8) 371.74
465645 PROPOFOL 1% LIPURO 50 ML 10 432.69 4326.90
29-1-07 CEBANEX 20 M 2 185.57 371.14
NITROJECT 5 ML INJ 2 55.76 111.52
RYLES TUBE 1 14.42 14.42
FOLLEYS CATHETER 14 1 86.53 86.53
CLEXANE 40 MG INJ 1 412.5 412.50
PANTOP INJ 1 51.97 51.97
HEP 25 INJ 1 96.15 96.15
DISPOSABLE SYRINGE 5 ML ROMO 10 6.73 67.30
DISPOSABLE SYRINGE 2 ML ROMO 10 6.73 67.30
NORMAL SALINE 100 ML VIAFLEX 5 59.00 295.00
NORMAL SALINE 500 ML VIAFLEX 3 61.00 183.00
NORMAL SALINE 500 ML (ALBERT D) 3 21.84 65.52
VAT CHARGES 246.00
TOTAL-(9) 6395.25
465726 INJ IVIGLOB EX 10 3327.20 33272.00
29-1-07 TOTAL-(10) 33272.00
465814 PROPOFOL 1% LIPURO 20 ML 4 195.00 780.00
29-1-07 CEBANEX 1 GM 2 99.00 198.00
ATEN 50 MG 6 2.19 13.14
VAT CHARGES 39.66
TOTAL-(11) 1030.80
SIR GANGA RAM HOSPITAL 168257 IMPACT ORAL PDR, 61 GMS 4 81.78 327.12
PHARMACY (COUNTER -II) 29-1-07 DISPO REGULAR DIAPERS 123…..(L) 1 613.33 613.33
VAT CHARGES 117.55
TOTAL-(12) 1058.00
SIR GANGA RAM HOSPITAL 466200 INJ (CEFOP+SAL TU) MAGNEX 2 GM 1 527.76 527.76
PHARMACY GROUND 30-1-07 CEBANEX 2GM 2 185.57 371.14
FLOOR PANTOP INJ 3 51.97 155.91
PROFOL 1% 50 ML 5 390.00 1950.00
GELOFUSINE 500 ML 5 230.00 1150.00
DISPOSABLE 50 ML ROMOJET 2 28.85 57.70
FOLLEYS CATHETER 14 1 86.53 86.53
I.V. SET (ROMSONS) 2 37.50 75.00
NORMAL SALINE 500 ML VIAFLEX 4 61.00 244.00
COTTON ROLL 250 GM 1 48.07 48.07
DISPOSABLE SYRINGE 10 ML ROMO 10 9.61 96.10
DISPOSABLE SYRINGE 5 ML ROMO 5 6.73 33.65
 NEEDLES FOR SYRINGE 6 1.68 10.08
VAT CHARGES 192.20
TOTAL-(13) 4998.14

466377 CLEXANE 60 IU INJECTION 1 514.5 514.50

30-1-07 VAT CHARGES 20.58
TOTAL-(14) 535.08
466546 INJ IVIGLOB EX 5 3327.20 16636.00
30-1-07 TOTAL-(15) 16636.00
SIR GANGA RAM HOSPITAL 168499 DISPO REGULAR DIAPERS 123…..(L) 1 613.33 613.33
PHARMACY (COUNTER -II) 30-1-07 VAT CHARGES 76.67
TOTAL-(16) 690.00
SIR GANGA RAM HOSPITAL 467346 INJ (CEFOP+SAL TU) MAGNEX 2 GM 2 527.76 1055.52
PHARMACY GROUND 1-2-07 INJ PANTOCID 40 MG 3 54.80 164.40
FLOOR NEZOLAM 1 ML 20 33.30 666.00
HEPALOCK INJ 6 6.95 41.70
NORMAL SALINE 500 ML VIAFLEX 5 61.00 305.00
M V I INJECTION 1 10.75 10.75
DISPOSABLE SYRINGE 10 ML ROMO 15 9.61 144.15
DISPOSABLE SYRINGE 5 ML ROMO 10 6.73 67.30
I V SET (ROMSONS) 2 37.50 75.00
RESOURCE POWDER 4 37.78 151.12
METOLAR 5 ML 1 8.85 8.85
DISPOSABLE 50 ML ROMOJET 1 28.85 28.85
VAT CHARGES 121.48
TOTAL-(17) 2840.12
SIR GANGA RAM HOSPITAL 169090 INJ ZOSYN 4.5 GM 2 995.00 1990.00
PHARMACY (COUNTER -II) 1-2-07 DALACIN - C 2 ML 300 MG INJ 4 104.24 416.96
VAT CHARGES 96.28
TOTAL-(18) 2503.24
169096 AMINOMIX 1500 ML 1 2390.00 2390.00
1-2-07 VAT CHARGES 95.60
TOTAL-(19) 2485.60
SIR GANGA RAM HOSPITAL 467847 DISPOSABLE 50 ML ROMOJET 2 28.85 57.70
PHARMACY GROUND 2-2-07 DISPOSABLE SYRINGE 10 ML ROMO 7 9.61 67.27
FLOOR DISPOSABLE SYRINGE 5 ML ROMO 7 6.73 47.11
DISPOSABLE SYRINGE 2 ML ROMO 5 6.73 33.65
DISPOSABLE SYRINGE 1 ML BD 5 6.25 31.25
NEEDLES FOR SYRINGE 5 1.68 8.40
NEOMOL 2 9.34 18.68
SODA-BI-CARB INJ 25 ML 3 15.38 46.14
ELASTOPLAST 1 432.69 432.69
VAT CHARGES 29.71
TOTAL-(20) 772.60
467852 INJ ZOSYN 4.5 GM 4 995.00 3980.00
2-2-07 INJ DALACIN-C 300 MG 2 ML 6 104.24 625.44
INJ NEWPAN 40 MG 3 53.00 159.00
NORALIN 2 MG INJ 20 124.03 2480.60
 467852
2-2-07

VOLUVEN 4 388.00 1552.00

NORMAL SALINE 500 ML VIAFLEX 2 61.00 122.00
NORMAL SALINE 100 ML VIAFLEX 5 59.00 295.00
I V SET (ROMSONS) 2 37.50 75.00
COTTON ROLL 250 GM 1 48.07 48.07
DISPOSABLE SYRINGE 20 ML ROMO 2 15.38 30.76
DISPOSABLE 50 ML ROMOJET 2 28.85 57.70
VAT CHARGES 377.00
TOTAL-(21) 9802.57
468021 ADRENOR INJ 6 125.00 750.00
2-2-07 HEP 25 INJ 2 96.15 192.30
VAT CHARGES 37.70
TOTAL-(22) 980.00
SIR GANGA RAM HOSPITAL 169273 DISPO REGULAR DIAPERS 123…..(L) 1 613.33 613.33
PHARMACY (COUNTER -II) 2-2-07 VAT CHARGES 76.67
TOTAL-(23) 690.00
169326 TARGOCID 400 MG INJ 1 1340.00 1340.00
2-2-07 INJ ADRENOR 5 125.00 625.00
NORALIN 2 MG INJ 5 124.03 620.15
ATROPINE INJ 1 ML 2 3.00 6.00
ATROPINE INJ 1 ML 13 3.00 39.00
ADRENALIN INJ 1 ML 10 4.50 45.00
P.D. CATHETER 1 779.81 779.81
P.D. I V SET 1 786.54 786.54
I V SET (ROMSONS) 1 37.50 37.50
DISPOSABLE SYRINGE 50 ML 5 25.96 129.80
DISPOSABLE SYRINGE 20 ML ROMO 5 15.38 76.90
DISPOSABLE SYRINGE 10 ML ROMO 10 9.61 96.10
URO BAG 1 38.46 38.46
CALCIUM GLUCONATE INJ 10 ML 5 14.00 70.00
VAT CHARGES 187.59
TOTAL-(24) 4877.85

GRAND TOTAL: (BILL TOTAL-(1) TO TOTAL-(24)) 145579.35

 CEERTIFICATE

It is certified that Mr. _____________________ son of Sh. _____________________

employed in the office ________________________________ has been under my
treatment at ________________________________________ my consultation room & that
the medicines mentioned hereunder have been prescribed by me in this connection were
absolutely essential for the treatment of recovery/prevention of serious and deteriorated
condition of the patient. The decidines were not stocked in the
______________________________________________ name of the propriority for which
cheaper substituted of equal value are available nor preparation which is primarily food/tonic
value are available nor preparation which is or disinfectent.

3.                  Certified that the medicines charges have no cheaper effective substitute.
4.                  Period of treatment from _______________ to __________________.
5.                  Certified that the medicines prescribed are not in the list of non-reimbursement
medicines particulars last revised in Govt. letter 170/1403/1581/RI/IRST-76/7706 dated
2-1-1957.
6.                  Certified that the prices claimed is reasonable.
7.                  He was suffering from _____________________.

Sr. No. Name of medicines Indoor ticket Dt. of which Amount

No./Dt. on which medicines
medicines actually
purchased/ purchased.
prescribed.

Signature & Designation

of authorized Medical attendant
1.                  Certified that my son/wife/daughter has no source of income of the own and is
actually residing with me and wholly depends upon me.
2.                  Certified that my basic pay is Rs.________________.
3.                  Certified that medicines have been actually purchased by me & full consumed
on the treatment of my ____________________.
4.                  Certified that the payment made by me in the Ist instance.
5.                  Certified that I am not claiming fixed medical allowance.
Signature of employee.
 CEERTIFICATE

It is certified that Ria Gandhi D/O Sh. Som Nath Gandhi employed in the office Retired Divisional
Suptt., PSEB(PSPCL) , Division Lalru has been under my treatment at PGI Chandigarh my
consultation room & that the medicines mentioned hereunder have been prescribed by me in this
connection were absolutely essential for the treatment of recovery/prevention of serious and
deteriorated condition of the patient. The decidines were not stocked in the hospital name of the
propriority for which cheaper substituted of equal value are available nor preparation which is
primarily food/tonic value are available nor preparation which is or disinfectent.

3.                  Certified that the medicines charges have no cheaper effective substitute.
4.                  Period of treatment from 12-09-2016 to 13-09-2016.
5.                  Certified that the medicines prescribed are not in the list of non-reimbursement medicines
particulars last revised in Govt. letter 170/1403/1581/RI/IRST-76/7706 dated 2-1-1957.

6.                  Certified that the prices claimed is reasonable.

7.                  He was suffering from Fracture shaft lt. femur, fracture pelvis & clavicle.

Sr. No. Name of medicines Indoor ticket Dt. of which Amount

No./Dt. on which medicines
medicines actually
purchased/ purchased.
prescribed.

201601526601

1 FESS (ENT/OTHORHINOLARYNGOLOGY ) 31.08.2016 1000

TOTAL (A) 1000
DISCOUNT
GRAND TOTAL (A) 1000.00
1 AXYCLAV 1.2 GM. INJ. (1 No.) 12.09.2016 125.00
2 CATHY IV CANNULA 20G X 1*1/2 (1No.) 12.09.2016 30.00
3 DISPOVAN SYRINGE 5ML/23 (4 No.) 12.09.2016 20.00
4 DISPOVAN SYRINGE 10ML *21G (4 No.) 12.09.2016 28.00
5 DISPOVAN SYRINGE 20ML (1 No.) 12.09.2016 12.00
6 DISPOVAN SYRINGE 50ML W/O (1 No.) 12.09.2016 27.00
7 ENCORE M/OPTIC GLOVES 7.0 (11 No.) 12.09.2016 825.00
8 PLANIN DRAPE D301 (1No.) 12.09.2016 99.00
9 MICROSHIELD 4 [747] H/W 1 (1No.) 12.09.2016 200.00
10 VACCU SUCK SUCTION SET (10 No.) 12.09.2016 350.00
11 HIV-RAPID TEST KIT (1 No.) 12.09.2016 79.75
12 HBS-AG RAPID TEST KIT (1No.) 12.09.2016 29.75
13 HCV RAPID TEST (1 No.) 12.09.2016 79.75
14 ADRENALINE INJ. 1 ML (8 No.) 12.09.2016 76.00
15 XYNOVA EITH ADR (1 VIAL) (1 No.) 12.09.2016 30.50
16 LOX 4% TOPICAL (1 No.) 12.09.2016 35.00
17 SURGICAL BLADE 15.0 (1 No.) 12.09.2016 3.00
18 1535-2 MICROPORE WITH CUT (1 No.) 12.09.2016 240.00
19 NEEDLE 23G (5 No.) 12.09.2016 5.00
20 MEROCEL NASALDRESSINGAIRW (4No.) 12.09.2016 1800.00
21 FUCIDIN OINT (2 No.) 12.09.2016 266.00
22 I.V. SET (ROMSONS) (1 No.) 12.09.2016 30.00
23 SPECI CAN Capacity 70 ml (2 No.) 12.09.2016 20.00
24 TRICUT BLADE 188400HR (1No.) 12.09.2016 6668.00
TOTAL (B) 11079
DISCOUNT -2618.23
GRAND TOTAL (B) 8461
 12.09.2016
TO
13.09.2016
1 NEOVEC 10 MG INJ. (1 No.) 12.09.2016 283.00
2 ALPHADEX 2ML INJ. (1 No.) 12.09.2016 600.00
3 E.T. TUBE CUFFED 7.5 (1 No.) 12.09.2016 150.00
4 E.C.G. ELECTRO-ARBO (6 No.) 12.09.2016 60.00
5 DICLOFAM 3ML INJ. (1 No.) 12.09.2016 5.17
6 EMESET 2MG INJ. 2ML (1 No.) 12.09.2016 14.00
7 DISPOVAN SYRINGE 10ML *21G (10 No.) 12.09.2016 70.00
8 DISPOVAN SYRINGE 5ML/23 (10 No.) 12.09.2016 50.00
9 DISPOVAN SYRINGE 50ML W/O (1 No.) 12.09.2016 27.00
10 I.V. SET (ROMSONS) (1 No.) 12.09.2016 30.00
11 B.T. SET (ROMSONS) (1 No.) 12.09.2016 30.00
12 CATHY IV CANNULA 20G X 1*1/2 (2No.) 12.09.2016 60.00
13 HIGH PRESSURE TUBE -200-M-200C 12.09.2016 65.00
LIFELIN (1No.)
14 SUCTION CATHETER (PLAIN) ROMSONS (1 12.09.2016 28.00
No.)
15 EXMINATION GLOVES 1BOX ANSELL (1No.) 12.09.2016 200.00

TOTAL (C) 1672

DISCOUNT -348.18
GRAND TOTAL (C) 1324
12.09.2016
TO
13.09.2016
1 AUGMENTIN 625 DUO (15 No.) 254.21
2 VOVERAN 50MG GE 15'S (6 No) 32.62
3 RAB 4U (10 No.) 64.50
4 SPORLAC DS TAB (20 No.) 74.14
TOTAL (D) 425
DISCOUNT -51.47
GRAND TOTAL (D) 374
12.09.2016
TO
13.09.2016
1 FUNGAL CUL TURE (ALLSPECIMENS) 14.09.2016 150.00
MEDICAL MICT)
2 BIOPSY (HISTOPATH) (HISTOPATHOLOGY) 14.09.2016 100.00

TOTAL (E) 250

DISCOUNT 0.00
GRAND TOTAL (E) 250
GRAND TOTAL (A) + (B) + 11409
(C) + (D) + (E)

Signature & Designation

of authorized Medical attendant
1.                  Certified that my daughter has no source of income of the own and is
actually residing with me and wholly depends upon me.
2.                  Certified that my basic pay/pension is Rs._30810/15405_______________.
3.                  Certified that medicines have been actually purchased by me & full consumed
on the treatment of my daughter.
4.                  Certified that the payment made by me in the Ist instance.
5.                  Certified that I am not claiming fixed medical allowance.
Signature of employee.
 CEERTIFICATE

It is certified that Ram Murti S/O Sh. Om Parkash employed in the office AEE/DS Sub Division,
PSEB, Dera Bassi has been under my treatment at Orthomax Bone & Joint Hospital, Sector-15,
Panchkula my consultation room & that the medicines mentioned hereunder have been
prescribed by me in this connection were absolutely essential for the treatment of
recovery/prevention of serious and deteriorated condition of the patient. The decidines were not
stocked in the hospital name of the propriority for which cheaper substituted of equal value are
available nor preparation which is primarily food/tonic value are available nor preparation which
is or disinfectent.
3.                  Certified that the medicines charges have no cheaper effective substitute.
4.                  Period of treatment from 17-12-2008 to 21-12-2008.
5.                  Certified that the medicines prescribed are not in the list of non-reimbursement
medicines particulars last revised in Govt. letter 170/1403/1581/RI/IRST-76/7706 dated 2-1-
1957.
6.                  Certified that the prices claimed is reasonable.
7.                  He was suffering from STI low back & haematome.

Sr. No. Name of medicines Indoor ticket No./Dt. on which Dt. of which Amount
medicines purchased/ medicines
prescribed. actually
purchased.
1 Thrombophob (1 No.) 271/17-12-2008 18-12-2008 49.00
2 Tab Chymoral forte (10 No.) 21-12-2008 180.60
3 Tab Ciplox 750 mg (10 No.) 21-12-2008 118.00
4 Tab Hifenac - D (10 No.) 21-12-2008 46.10
TOTAL (A) 393.70
HOSPITAL CHARGES 96/31-1-2009 17-12-2008
to
21-12-2008
1 Surgeon charges 1000.00
5 Room charges (4x1200) 4800.00
6 Nursing charges (4x300) 1200.00
7 OT consumables 765.00
9 X-ray (2x100) 200.00
10 Physiotherapy (4x100) 400.00
TOTAL (B) 8365.00
GRAND TOTAL (A) + (B) 8758.70

Signature & Designation

of authorized Medical attendant
1.                  Certified that my son/wife/daughter has no source of income of the own and is
actually residing with me and wholly depends upon me.
2.                  Certified that my basic pay is Rs.________________.
3.                  Certified that medicines have been actually purchased by me & full consumed
on the treatment of my ____________________.
4.                  Certified that the payment made by me in the Ist instance.
5.                  Certified that I am not claiming fixed medical allowance.
Signature of employee.
 CEERTIFICATE

It is certified that Ram Murti S/O Sh. Om Parkash employed in the office AEE/DS Sub
Division, PSEB, Dera Bassi has been under my treatment at Swami Nursing Home, Teh.
road Dera Bassi my consultation room & that the medicines mentioned hereunder have
been prescribed by me in this connection were absolutely essential for the treatment of
recovery/prevention of serious and deteriorated condition of the patient. The decidines
were not stocked in the hospital name of the propriority for which cheaper substituted of
equal value are available nor preparation which is primarily food/tonic value are available
nor preparation which is or disinfectent.

3.                  Certified that the medicines charges have no cheaper effective substitute.
4.                  Period of treatment from 15-12-2008 to 17-12-2008.
5.                  Certified that the medicines prescribed are not in the list of non-reimbursement
medicines particulars last revised in Govt. letter 170/1403/1581/RI/IRST-76/7706 dated
2-1-1957.
6.                  Certified that the prices claimed is reasonable.
7.                  He was suffering from STI low back & haematome.

Sr. No. Name of medicines Indoor ticket No./Dt. on Dt. of which Amount
which medicines medicines
purchased/ prescribed. actually
purchased.
HOSPITAL CHARGES 15-12-2008 to
17-12-
1 Admission fee 2008 100.00
2 Room charges (2x400) 800.00
3 X-ray (4x100) 400.00
4 Nursing charges (2x300) 600.00
5 Doctor fee (2x300) 600.00
TOTAL (A) 2500.00
1 MRI charges 16-12-2008 3750.00
2 15-12-2008 to 300.00
17-12-
3 2008 80.00
4 80.00
5 40.00
6 20.00
7 15.00
8 15.00
9 150.00
10 50.00
11 100.00
TOTAL (B) 4600.00
GRAND TOTAL (A) + (B) 7100.00

Signature & Designation

of authorized Medical attendant
1.                  Certified that my son/wife/daughter has no source of income of the own and is
actually residing with me and wholly depends upon me.
2.                  Certified that my basic pay is Rs.________________.
3.                  Certified that medicines have been actually purchased by me & full consumed
on the treatment of my ____________________.
4.                  Certified that the payment made by me in the Ist instance.
5.                  Certified that I am not claiming fixed medical allowance.

Signature of employee.
 CEERTIFICATE

It is certified that Neha Gupta D/O Sh. Ram Murti employed in the office AEE/DS Sub
Division, PSEB, Dera Bassi has been under my treatment at Swami Nursing Home
Teh. road Dera Bassi my consultation room & that the medicines mentioned hereunder
have been prescribed by me in this connection were absolutely essential for the
treatment of recovery/prevention of serious and deteriorated condition of the patient.
The decidines were not stocked in the hospital name of the propriority for which
cheaper substituted of equal value are available nor preparation which is primarily
food/tonic value are available nor preparation which is or disinfectent.

3.                  Certified that the medicines charges have no cheaper effective substitute.
4.                  Period of treatment from 15-12-2008 to 16-12-2008.
5.                  Certified that the medicines prescribed are not in the list of non-reimbursement
medicines particulars last revised in Govt. letter 170/1403/1581/RI/IRST-76/7706 dated
2-1-1957.
6.                  Certified that the prices claimed is reasonable.
7.                  He was suffering from Fracture shaft lt. femur, fracture pelvis & clavicle.

Sr. No. Name of medicines Indoor ticket No./Dt. on Dt. of which Amount
which medicines medicines actually
purchased/ prescribed. purchased.

1 15-12-2008 to 40.00
16-12-2008
2 15.00
3 15.00
4 20.00
5 70.00
TOTAL (A) 160.00
1 X-ray (3x100) 15-12-2008 to 300.00
16-12-2008
2 Room rent (1x400) 400.00
3 Doctor fee (1x200) 200.00
TOTAL (B) 900.00
GRAND TOTAL (A) + (B) 1060.00

Signature & Designation

of authorized Medical attendant
1.                  Certified that my son/wife/daughter has no source of income of the own and is
actually residing with me and wholly depends upon me.
2.                  Certified that my basic pay is Rs.________________.
3.                  Certified that medicines have been actually purchased by me & full consumed
on the treatment of my ____________________.
4.                  Certified that the payment made by me in the Ist instance.
5.                  Certified that I am not claiming fixed medical allowance.

Signature of employee.
 CEERTIFICATE

It is certified that Rekha W/O Sh. Ram Murti employed in the office AEE/DS Sub
Division, PSEB, Dera Bassi has been under my treatment at Swami Nursing Home
Teh. road Dera Bassi my consultation room & that the medicines mentioned hereunder
have been prescribed by me in this connection were absolutely essential for the
treatment of recovery/prevention of serious and deteriorated condition of the patient.
The decidines were not stocked in the hospital name of the propriority for which
cheaper substituted of equal value are available nor preparation which is primarily
food/tonic value are available nor preparation which is or disinfectent.

3.                  Certified that the medicines charges have no cheaper effective substitute.
4.                  Period of treatment from 15-12-2008 to 19-12-2008.
5.                  Certified that the medicines prescribed are not in the list of non-reimbursement
medicines particulars last revised in Govt. letter 170/1403/1581/RI/IRST-76/7706 dated
2-1-1957.
6.                  Certified that the prices claimed is reasonable.
7.                  He was suffering from __________________________.

Sr. No. Name of medicines Indoor ticket No./Dt. on Dt. of which Amount
which medicines medicines actually
purchased/ prescribed. purchased.

1 15-12-2008 to 40.00
19-12-2008
2 40.00
3 10.00
4 50.00
5 80.00
80.00
TOTAL (A) 300.00
1 MRI charges 16-12-2008 5000.00
2 Admission fee 15-12-2008 to 100.00
19-12-2008
3 Room rent (4x400) 1600.00
4 X-ray (4x100) 400.00
5 Doctor fee (4x200) 800.00
TOTAL (B) 7900.00
GRAND TOTAL (A) + (B) 8200.00

Signature & Designation

of authorized Medical attendant
1.                  Certified that my son/wife/daughter has no source of income of the own and is
actually residing with me and wholly depends upon me.
2.                  Certified that my basic pay is Rs.________________.
3.                  Certified that medicines have been actually purchased by me & full consumed
on the treatment of my ____________________.
4.                  Certified that the payment made by me in the Ist instance.
5.                  Certified that I am not claiming fixed medical allowance.

Signature of employee.
 CEERTIFICATE

It is certified that Sharda Devi Mother of Sh. Premjeet Kumar Ram employed in the office LDC,
PSEB(PSPCL), Division Lalru has been under my treatment at National Dental College & Hospital,
Gulabgarh Road Dera Bassi my consultation room & that the treatment mentioned hereunder have
been done by me.

2.                  Period of treatment from 13-05-2017 to 03-06-2017.

3.                  Certified that the prices claimed for the dental treatment mentioned below is reasonable.

Sr. No. Name of dental procedure outdoor ticket Dt. of which Amount
No./Dt. on which dental
treatment procedure
mentioned. done
PART-A HOSPITAL CHARGES 20863/13.05.2017 13.05.2017 10

1 X Ray 13.05.2017 30.00

2 U/S Scaling 13.05.2017 85.00
3 For Restoration 37 13.05.2017 200.00
4 PFM 3 15.05.2017 2850.00

TOTAL 3175

Signature & Designation

of authorized Medical attendant
1.                  Certified that my basic pay/pension is Rs._11160/-
2.                  Certified that payment of treatment of my mother actually paid by me.
3.                  Certified that the payment made by me in the Ist instance.
4.                  Certified that I am not claiming fixed medical allowance.

Signature of employee.