Medical Advance Application form pdf download for Central Government Employees

Medical Advance application form. Download Medical Advance form for Central Government Employees. Medical Advance form pdf download. Advance Application forms for Government Employees.

APPLICATION FOR ADVANCE FOR MEDICAL

TREATMENT

1.	Name.
2.	Designation and Office in which working.
3.	Basic Pay + NPA + SI
4.	Whether permanent or temporary.
5.	Name of the patient and relationship with the Government Servant.
6.	Nature of illness.
7.	Whether treatment is received as Inpatient or Out-patient.
8.	Name of the Hospital in which patient is treated and whether it is a recognised one.
9.	Whether necessary certificate from the Medical Officer or Specialist of the recognised hospital is enclosed.
10.	Anticipated cost of treatment as certified by the Medical Officer/Specialist.
11.	Amount of advance required.

I declare that the particulars furnished above are correct.

Station :

                                                                                                Signature of the Government Servant. 

Date :-