ESSENTIALITY CERTIFICATE

CERTIFICATE -- A

 

(To be completed in the case of patients who are not admitted to hospital for treatment.)

 

                Certificate granted to Dr./Mr./Mrs./Miss _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ wife/son/daughter of                   Mr./Dr./Mrs. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  employed in the

1.             I,  Dr. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ hereby Certify:-

(a)  That I charged and received Rs. _ _ _ _ _  _ _ _ _ _ _ _ _ _ for _ _ _ _ _ _ _ _  _ _ _ consultations  on                                     _ _ _ _ _ _ _ _ _ _ _ _ (date to be given) at my consulting room/ at the residence of the patient/at hospital.

(b) That I charged and received _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ for administering                                                  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ intra-venous/intra-muscular/Subcutaneous injection on                                             _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(date to be given)  at hospital/ at my consulting                                                     room/ at the residence of the patient.

                (c)  That the injections administered were not/ were not immunizing or prophylactic purpose.

(d) That the patient has been under treatment at _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  hospital/my consulting room and that the under mentioned 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 hospital) for supply to private patients and do not  include proprietary preparations for which cheaper substance of equal therapeutic value are available nor preparations which are primarily foods toilets or disinfectants.

S.No.                 NAME OF MEDICINES (IN BLOCK LATTERS)                             QUANTTITY                       PRICE

1-

2-

3-

4-

5-

6-

7-

8-

(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-natel or post-natal treatment.

(g) That the x-ray, laboratory test etc., for which an expenditure of Rs._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ was incurred was necessary and are undertaken on my advice at_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (name of hospital/laboratory).

(h) That I referred the patient to Dr._ _ _ _ _ _  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ of specialist consultation and that the necessary approval of the  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (name of chief) administrative officer of the State) as required under the rules was obtained.

(i) That the patient did not require/ requires hospitalization.

 

 

  Signature and Designation of the                                                                                                                                               Medical Officer & Name of the

Hospital & Dispensary to which

                                                                                                       attached.

CERTIFICATE – B

 

(To be completed in the case of patients who are admitted to hospital for treatment)

 

Certificate granted to Mrs/Mr/Miss _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ wife/son/daughter of Mr. _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _  employed in the _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

 

PART – A

(To be signed by the Medical Officer in charge of the case at the hospital)

 

1.        I, Dr. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ _ _ _ _ _ _  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ hereby certify

          

(a)     That the patient was admitted to hospital on my advice/ The advice of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _   _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

                                                                                  (Name of Medical Officer)

 

       (b)   That the patient has been under treatment at _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ _  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

              and that undermentioned medicines prescribed by me in this connection were essential for the recovery/prevention   

              of serious deterioration in condition of the patient.

2.        The medicines are not stocked in the _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ for supply to private patients and so not include proprietary preparations for which cheaper substances of equal therapeutic value are available not preparations which are primarily foods, toilets.

-------------------------------------------------------------------------------------------------------------------------------------------------------

Sl.No.                                             NAME OF MEDICINES                                                              PRICE

1.

2.

3.

4.

5.

6.

7.

 (c)  That the injections administered were/were not for immunising or prophylactic purpose.

(d)     That the patient is/was suffering from _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _and is/was under my treatment from _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ to_ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _  _ _ _ _ _ _ _ _ _ _ _

(e)     That the X-Ray,  Laboratory etc. for which an expenditure of Rs._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ was incurred were necessary and were undertaken on my advice at _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

                                                                                                                          (Name of the hospital or Laboratory)

(f)      That referred that patient to Dr. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ for specialist consultation and that the necessary approval of the _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

                          (Name of the Chief Administrative Medical Office of the State)

        _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ as required under the rules was obtained.

 

       Signature and Designation of the

           Medical Officer in Charge of the

                                                                                                                                                Case at the hospital.

 

 

PART –B

              I certify that the patient has been under treatment at the _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  hospital and that the services of the special nurses for which an expenditure of Rs. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ was incurred vide bills and receipts attached, were essential for the recovery/prevention of serious deterioration in the condition of the  patient.

 

 

                                                                                                                                    Signature of the Medical Officer in

                                                                                                                                   Charge of the case at the hospital.

 

                                 C  O  U  N  T  E  R  S  I  G  N  E  D

                                                      _ _ _ _ _ _ _ _ _ _ _ _ _ _  Medical Superintendent                 

                                    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  Hospital

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -  - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 

                I certify that the patient has been under treatment at the_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _   hospital and that the facilities provided were the minimum which were essential for the patient’s treatment.

 

                                                                                                                _ _ _ _ _ _Medical Superintendent                            

                                                                                                              _ _ _ _ _ _ _Hospital