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Proforma for reimbursement of medical expenses by esic
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Proforma for reimbursement of medical expenses by esic


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  • 1. PROFORMA FOR REIMBURSEMENT OF MEDICAL EXPENSES TO INSURED PERSONS ( To be filled by the Medical Officer of Private Medical Institution ) Whether the case was an emergent one (Nature of emergency to be specified) 1. Diagnosis of the case : Whether the case was admitted on requisition from the Insurance Medical Officer / IMP. if not, Whether the case would have Ordinary been referred by IMO / IMP Concerned for in – patient treatment. : 2. The dates of admission and discharge of the patient from the hospital stoppages costly/ special medicines record from the Insured Person. : 3. The class of accommodation provided for the patient. : 4. Whether it was discolosed that he or who is the family member of the Insured Person and is is eligible for medical benefits under the ESI Scheme at the time of admission or after admission of the date. : 5. (a) Whether the case was admitted and was provided with in - patient treatment in special ward. (b) If so, whether such a special ward treatment was provided to the case or by the Insured Person or : by any of his relatives or such a special ward was provided to the case on the basis of the monthly income of Insured Person. 6. The charges which would have been collected, if the case was treated in the General Ward itself instead of in the special ward during the entire period of treatment. 7. Whether the Insured Person was advised to purchase the medicines from open market. : : 8. Details of X - ray, operation medicines, Lab test etc., may be furnished in the prescribed proforma enclosed. : 9. Whether the health condition of the patient was such that any delay. 10. In admitting him either in the ESI Hospital or into Government Hospital would seriously jeopardized his health conditions. : : Signature of the Medicial Officer of Private Medical Institute. Seal:
  • 2. P R O FO R M A 1. Hospital stoppages Admission 2. Total No. of days Total Medicines Details of medicines given 3. Rate per day Quantity Amount charged X- Ray Details of X – ray taken Amount charged Details of tests done Amount charged