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West Bengal Health Scheme 2008 FORM IV1 Essentiality Certificate Cum Statement of Expenditure Certified by Treating Specialist for OPD Treatment. See sub-para ii of para 11 of the memo no. 3475 F dt. 11. 05. 09. and clause-7 1 of the Health Scheme Name of the Govt* pensioner / family pensioner with identification No* Name of Office of the Office of the Ex-Govt* employee / Govt* Pensioner / Pension Sanctioning Authority Name of the patient relationship with Ex-Govt* Employee Identification No* Details of expenditure I II Name Code No* of the empanelled / Govt* recognized Hospital III Period of OPD treatment IV Total No* of original bills vouchers V Sl* No* Name of the diagnosed disease vide list enclosed Amount claimed for OPD treatment Description of items a Consultation fees indicate total no. of consultations b Pathological investigations give Break-up in a separate annexure with code no. c Radiological investigations attach separate list if required with code no. d Medicines give details of purchase in separate annexure if required Rupees Amount admissible for official use e Special devices like hearing aid / artificial appliances etc* specify f Miscellaneous specify Total only Signature of Claimant Name in Block Letters Address 3. Certified that the relevant bills/vouchers have been verified by me in pursuance of the latest approved rates of the WBHS 2008 and the expenditures shown above are correct and the treatment services prescribed and provided were essential and minimum that required for the recovery of the patient. fromas listed in Sl* No* of the WBHS OPD list below. Counter signed by Signature of the Treating Specialist with official seal Administrative officer/Medical Superintendent of the recognized Hospital with official seal OPD Disease List as per clause 7 1 of the WBHS 2008 i Malignant diseases ii Tuberculosis iii Hepatitis B/C and other liver diseases iv -dependent diabetes v Heart diseases vi Neurological disorders/Cerebrovascular disorders vii Malignant malaria viii Renal failure ix Thallasaemia/Bleeding disorders/Platelet disorders x Injuries caused by accidents. xi None of the above list Specify name of the ailment vide Para-10 of Memo No* 797-F MED dated 31-01-2011. See sub-para ii of para 11 of the memo no. 3475 F dt. 11. 05. 09. and clause-7 1 of the Health Scheme Name of the Govt* pensioner / family pensioner with identification No* Name of Office of the Office of the Ex-Govt* employee / Govt* Pensioner / Pension Sanctioning Authority Name of the patient relationship with Ex-Govt* Employee Identification No* Details of expenditure I II Name Code No* of the empanelled / Govt* recognized Hospital III Period of OPD treatment IV Total No* of original bills vouchers V Sl* No* Name of the diagnosed disease vide list enclosed Amount claimed for OPD treatment Description of items a Consultation fees indicate total no. of consultations b Pathological investigations give Break-up in a separate annexure with code no. c Radiological investigations attach separate list if required with code no.

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