Get Medical Claim Extract Form - Pondicherry Police

Filling out the Medical Claim EXTRACT Form for the Pondicherry Police is an important process to ensure that you receive the necessary medical reimbursements. This guide will provide you with clear instructions to help you complete the form accurately and efficiently online.

Follow the steps to fill out the Medical Claim EXTRACT Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, provide the name of the government servant, including their designation and the section they are working in, along with the pay drawn.
3. Next, enter the residential address of the government servant and the location where the patient fell ill.
4. Fill in the name of the patient and their relationship to the government servant. If the patient is a child, include their age.
5. Detail the name of the disease, along with the period of medical attendance and treatment, as noted in the Essentiality Certificate.
6. For treatment other than in-patient, specify the name of the authorized medical attendant and the hospital to which they are attached.
7. List the fees paid to the authorized medical attendant, including the receipt number and date.
8. Provide the details of consultations and injections: number and date of consultation, any injections administered, and respective dates.
9. List the names of the medicines prescribed that are included in Certificate 'A', along with details of the cash memo, including the name of the company and the bill number and date.
10. Include any radiology and other costs mentioned in Certificate 'A', with receipts and amounts specified.
11. In the case of inpatient treatment, fill out the details of hospital stoppages, including the receipt number and date.
12. List the allocation of charges for medical advice, nursing, accommodation, diet, and medicines.
13. Enter the details of other charges, if applicable, and calculate the grand total.
14. Finally, sign the declaration affirming that all the particulars provided are correct to the best of your knowledge and belief.
15. After filling out the form, save the changes. You can also download, print, or share the completed form as required.

Complete and submit your Medical Claim EXTRACT Form online today to ensure timely processing of your claim.