How to apply for Essentiality Certificate ‘A’ for Medical Reimbursement?

                                                       Essentiality Certificate ‘A’

(To be completed in the case of patients who are NOT ADMITTED to hospital for treatment)

Certificate granted to Mrs./Mr./Miss……………………………………………….. Wife/Son/Daughter of MR/MRS/MISS ……………………………………….. employed in

I, Dr. ………….……………………………………….. hereby certify :-

(a) that I charged and received Rs. ..………………. for ………….. consultations on ……………. (dates to be given) at my consulting room/ at the residence of the patient;

(b) that I charged and received Rs……………… for administering ..……… intra- venous/intra-muscular/subcutaneous injections on…………(dates to be given) at………………….. my consulting Room/the residence of the patient;

(c) that the injections administered were not/were for immunising or prophylactic purposes;

(d) that the patient has been under treatment at ………. …………………. hospital/ my consulting room and that the undermentioned 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 …………………………………… (name of the hospital) for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparations which are primarily food, toilets or disinfectants.

Name of medicines                              Price
1
2.
3.
4.

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

(f) that the patient is/was not given pre-natal or post-natal treatment;

(g) that the X-ray laboratory test, etc., for which an expenditure of Rs. ……. was incurred was necessary and were undertaken on my advice at ………… (name of the hospital or laboratory);

(h) that I referred the patient to Dr. ………………………….. for SPECIALIST consultation and that the necessary approval of the ………………………….. (Name of the Chief Administrative Officer of the State) as required under the rules was obtained;

(i) that the patient did not require/required hospitalisation.

Signature of AMA/Designation of the Medical officer and hospital/ dispensary to which attached.

Dated :- ———-

Note :
Certificates Not Applicable Should Be Struck Off. Certificate (e) Is Compulsory And Must Be Filled In By The Medical Officer In All Cases.

Download Application Form Here :   https://www.indianjobtalks.in/uploads/12317-medical%20essential%20certificate-A.pdf