ESSENTIALITY CERTIFICATE

1. I certify that Late Sh. Harbans Singh S/o Sh. Chet Singh Retired as Tehsildar

from Tehsil Mansa and resident of Chaudhary Chet Singh Street, Jaitu, District Faridkot was under my treatment at Dr. Bharat Bhushan Jindals Complete Medical Centre, Power House Road, Bathinda in my consulting room at Bathinda and that under mentioned medicine prescribed by me in this connection were absolutely essential for the treatment/recovery/prevention of serious deterioration in the condition of the patient. The medicines were stocked in the hospital, for which cheaper substitute of equal therapeutic value are available not preparations which are primary food, tolleter or disinfections. 2. Certified that treatment as indoor patient was necessary. 3. Certified that those prices claimed are reasonable. 4. Certified that medicines charged have no cheaper effective substitutes.
5. Period of treatment 19-07-2011 to 21-07-2011. 6. Certified that the medicines are not in the nature etc. or medicines which are in

the nature of tonic/foods were prescribed as medicines as essential as the cost of which is not reimbursable under Govt. Order issued on the subject from time to time. 7. He was suffering from ...........................................................................

Qty. Name of medicine 1 1 2 1 4 4 3 2 3 1 4 2 2 2 6 6 1 1 1 1 5 4 2 4 2 2 4 6 2 2 1 1 Kit Kath Fixer IV Set Paper Tape 5 CC Syringe 10 CC Srringe N. Saline 100ML N. Saline 500ML Inj. Microtaz 4.5 gm Inj. Dopamine Inj Cort-S 100mg Inj Aciloc 2ml Combimist Raspules Inj Oxprin 60 mg Tab CATT 40 mg Tab Clavax AS 150 Catheter No. 16 Uro Bag Jelly Gloves No. 7 E.C.G. Electrode N. Sline 500 Ml N. Sline 100 Ml Inj. Microtaz 4.5 gm Inj. Dopamine Inj. Oxprin 60 mg Inj Cort-S 100mg Combimist Raspules Inj. Aciloc Inj. Panfast 40 mg Cremafin Syrup IV Set

Indoor No./Admn No and date 201 Dt. 19.07.2011

Date of purchase 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 19.07.2011 20.07.2011 20.07.2011 20.07.2011 20.07.2011 20.07.2011 20.07.2011 20.07.2011 20.07.2011 20.07.2011 20.07.2011 20.07.2011

Amount 70.00 35.00 116.00 33.00 20.00 32.00 39.00 34.00 1380.00 35.00 216.00 6.00 8.00 1070.00 144.00 15.00 340.00 95.00 45.00 45.00 100.00 68.00 26.00 1840.00 70.00 1070.00 216.00 24.00 6.00 118.00 70.00 58.00 7444.00

Total (1) Detail of other expenses

Sr. No. 1

Name of Hospital Bhushan Jindals Complete Medical Centre, Bathinda Bhushan Jindals Complete Medical Centre, Bathinda Bhushan Jindals Complete Medical Centre, Bathinda Mittal Labs

Description Admission Fees

Receipt no & date

Amount 500.00

ICCU Bed Charges for Three days Nursing Charges

6000.00

500.00

Medical Examinations CBC RBS OT PT CRE LIPID Uric Acid Total (2) Grand Total (1) +(2)

424 Dt 19.07.2011 150.00 120.00 50.00 50.00 50.00 350.00 50.00 7880.00 15324.00

Declaration
1. I hereby declare that medicine purchased for the treatment of the patient has

been actually purchased by me and consumed by my father. 2. I hereby declare that the treatment for him for the above period has not got done from other hospital and further certify that claim stated above is accurate. 3. I hereby declare that my father had retired as Tehsildar from Mansa on 31.10.1987. 4. I hereby declare that my father was living at Choudhary Chet Singh Street, Jaitu, District Faridkot.

Signature of claimant