PROFORMA FOR TREATMENT ABROAD CASES

(FILLED BY THE TREATING DOCTOR)

1.	Name of the Beneficiary	:
2.	Designation	:
3.	Name of the Office	:
4.	Complete Address of Office	:
5.	Name of Patient	:
6.	Relationship of the patient with Beneficiary	:
7.	Diagnosis	:
8.	Brief history of the patient	:
9.	Details of important investigative/ diagnostic procedures /medical/ surgical treatment already carried out.	:
10.	Recommendation of the treating doctor justifying treatment abroad.	:
11.	Endorsement of Head of Department with reasons justifying treatment abroad	:
12.	Certificate to the effect that the treatment for the disease is not available in India, to be countersigned by the Head of the Department/MS of the Hospital	:
13.	Whether Attendant required/not required. If required, whether the Attendant should be medical/para medical personnel or otherwise giving full justification for the same.	:
14.	If not available in India, where (in which country/hospital) the treatment could be taken.	:

Dated:

Signature of Treating Doctor

(With stamp)