ffjoH yd mqoa., yosis wk;=re rlaIK l%uh

ysulus b,a,qus m;%h ^w.%ydr&

^b,a,qñ m;%h msrùug fmr fñ iu. we;s Wmfoia m;%sldj lshjkak'&

1' b,a,quslre ms<ssno f;dr;=re()

1'1 සම්පූර්ණ ku() ^isxyf,ka& mQcH$uhd$ush$fukjsh( '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

uq,l=re iu. ku ^bx.%Sisfhka&()---------------------------------------------------------------

1'2 ඉල්ලුම්කරුෙග් ජාතික හැඳුනුම්පත් අංකය

^Pdhd msgm; wuqKkak&

1'3 mqoa.,sl ,smskh ^bx.%Sisfhka&() '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

^isxyf,ka&()-----------------------------------------------------------------------------------

1'4 Wmka oskh() '''''''''''''''''''''''''''''''''''''''''''''''''

1'5 දුrl:k wxlh () rdcldrs''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 'mqoa.,sl''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

1'6 B-fñ,a ,smskh (-………………………………………………………………………

2 /lshdj ms,sno f;dr;=re (-

2'1 ;k;=r (-''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

2'2 Tn /lshdj lrk wdh;kfha ku iy ,smsskh ()''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

2'3 fuu jifrA ia:dk udrejla ,enqfú kñ fmr fiajd ia:dkfha ku yd ,smskh

'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

3 l,;%hdf.a f;dr;=re

3'1 cd;sl හැඳුනුම්පත් wxlh()

3'2 ku()'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

3'3 fiajd ia:dkfha ku iy ,smskh()''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

34 ;k;=r (-''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

 

Tnf.a ysâlu wod, jkafka

bosrsfhka ^√& oukak' rcfha fm!oa.,sl ore Wm;la weialkaKdõ yDo ie;alula ms<sld ෙහෝ frday,l frday,l ෙවනත් ෙරෝග

දැනුම් දීමට අවශ  ෙකටි පණිවුඩ (SMS)         තැපැල්                              (අවශ මාධ ය ලකුණු කරන්න) 

ෙහෝ

4' rCIK m%%;s,dN ඉල්ලුම් lrkafka ()Tng fyda l,;%hdg fkdෙව kම් wod, fldgfia ^√& fhdod සම්පූර්ණ lrkaak'

4'1 orejkag( ujg( mshdg(

4'2'1 Tyqf.a$wehf.a ku()'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

4'2'2 Tyqf.a$wehf.a Wmka oskh () ''''''''''''''''''''''''''''''''''' jhi '''''''''''''''''''''''' /lshdj'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

5 m%;sldr ms,sno õia;r (- 5'1 frda.h fyda Y,Hl¾uh (-……………………………………… 5'2 wfmalaIs; ysïlï uqo, (-………………………………………………

6' nexl= .sKqම් ms,ssnඳ ව්iaa;rh () ^Tnf.a fm!oa.,sl nexl= .sKqu - cd;sl b;srs lsrSfï nexl=j " uyck nexl=j " ,xld nexl=j " iïm;a nexl=j " fldurAI,a nexl=j" fi,dka nexl=j "yegka keIk,a nexl=j " fkaIka g%iaÜ nexl=j " cd;sl ixjraOk nexl=j " mEka tAIshd nexl=j " fydxfldx wekaâ Iekayhs nexl=j iagEkavâ pd¾gâ nexl=j hk nexl=j,g wh;a .sKqula úh hq;=h&

5'1 nexl= .sKqෙම i|yka Tnf.a ku(- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

5'2 .sKqම් wxlh 5'3 nexl=fï ku(- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' nexl= YdLdj(- ''''''''''''''''''''''''''''''''''''''''''''''''''

7' fuu whÿñm;g wod, úhoñ fjk;a wdh;khlska m%;smQrAKh lr ;sfí kñ fyda whÿñlr ;sfí kñ 7'1 wdh;kfha ku iy ,smskh (-…………………………………………… ……………………………………………………………………… 7'2 f.jq uqo, (-……………………………………………………… 7'3 ysïlï wxlh$fhduq wxlh (-…………………………………………

8' w.%ydr rlaIK l%uh hgf;a Tn ,ndf.k we;s m%;s,dN ms,sno úia;r

ysïlï j¾.h osskh ,enQ uqqo, weia lKaKdvs …………… … ……………… ore Wm;a ……………… ……………… fjk;a frda.$ ……………… ……………… ie;alï

9' whÿñlref.a m%l%ldYh by; ioyka f;dr;=re i;H yd ksjros nj;a" fuu ysïslïmEu by; 07 fcaohg hg;aj fjk;a rlaIK wdh;khlska" fjk;a l%uhla u.ska fyda ta ioyd b,a,Sula bosrsm;alr fyda fkdue;s nj uu fuhska iy;sl fjñ' udf.a l,;%hd úiska fyda fï fjkqfjka lsisoq rlaIK m%;s,dNhla ,nd fyda b,a,Sula bosrsm;a lr fkdue;s njg;a uu iy;sl fjï' rdcH mrsmd,k pl%f,aLk wxl 12$2005 ys 08" iii j.ka;sh m%ldr jHdc f,aLK bosrsm;a lsrSfuka ysïlïmdkq ,nk ks,OdrShd jeroslrefjl= jqjfyd;a wdh;k ix.%yfha ii lKavfha XLViii jeks mrsÉfPaofha úêúOdk yd oKavkS;S ix.%yfha úèõOdko wkqj l%shd lrkq ,nk nj uu oksñ' ysñlñ f.ùu wxl 06 hgf;a i|yka nexl= .sKqug ner lrk f,i b,a,d isáñ' oskh …………… ………………………

whÿñlref.a w;aik

මරදාන පාර" පාර" fld<U 10" wka;ර්cd,h ( www.nitf.lk

oqrl:k wxl ( 0114)873901)5 Bෙම්,a ( mail@nitf.lk *elaaia () 0114 ) 702667

10' wdh;k m%Odksshf.a iy;slh (-

uf.a wxlh (………………

by; úia;r ioyka ………………………………uy;d$uy;añhf.a rlaIK ysñlu wjYH lghq;= ioyd ks¾foaYlr fñ iu. bosrsm;a lrñ' by; ioyka f;dr;=re i;H yd ksjros nj;a " Tyqf.a $wehf.a fm!oa.,sl ,smsf.dkqj wkqj

iy;sl lrñ' rlaIs;hd m%;sldr ,en frdayf,ka neyerjq udihg fmr udih jq ……………… udifha odhl uqo,

whlr ………………………… nexl=fú .......................YdLdfú wxl ...................... orK fplam;ska cd;sl rlaIK

Ndr wruqof,a uyck nexl=fú /csk YdLdfú 033-2-001-2-2467951 orK .sKqug nerl< remsh,a ....................... l uqM uqo,g we;=,;a lr we;'

w;aik .......................

ku …………………………………….

;k;=r …………………………………

oskh ....................... ^ks, uqøj ;eîu w;HjYHhhs&

11' frda.sshdf.a ffjoHjrhd$Y,H ffjoHjrhd õiska iñmQQrAK l< hq;qh'

Should be filled by the Medical Officer/Surgeon of the patient.

11'1 frda.shdf.a ku ………………………………………………………………

Name of the Patient :……………………………………………………….. 11'2 frda. úksYaph ………………………………………………………………

………………………………………………………………………………..…… Diagnosis of disease:…………………..…………………………………… ……………………………………………………………..……………..…

11'3 idudkH rdcldrS lghq;= j, ksr;ùug fkdyels ld, iSudj (- ……………………………….osk

isg…………………….……….osk olajd

Period unable to attend to usual business/works: From:-………………….…… To-……………….………

11'4 frday,g we;=,;a l, oskh (-………………….……………………………

msgjq oskh (-………………………………………………

If admitted to the hospital, Date of admission………………………….. Date of discharge…………………………..

by; ioyka frda.shdf.a ffjoHjrhd$Y,H ffjoHjrhd ud nj;a" fuu b,a,Su iñnkaOjQ fiajdj uu wkqu; l, nj;a iy;sl lrñ'

……………………………………… frda.shdg m%;sldr l, ffjoHjrdf.a$ úfYaI{ ffjoHjrhdf.a w;aik yd ks, uqødj

oskh (-………………………………

I hereby certify that I am Medical Officer/Surgeon of the above named patient and approve submission with regard to this claim. Date …………………… ………………………………………

Signature of Medical Officer/Surgeon whÿñm; iñmQrAK iñmQrQrAKAK lsrsrSuSu i|yd Wmfoia

^fmdararu wxl A I frday,a .;úï yd ie;alï " yDo ie;alï " ore Wm;a" weia lKaKdvs"s" ms<sld jl=.vq wdoS frdaa. j,g wod, ysïlï b,a,qqï lsrsSu i|yd muKs's's'& 1' frday,ska msgú osk 90 we;=,; ysïlï whoqïm; cd;sl rCIK Ndr wruqo, fj; fhduq l, hq;=h' 2' Tn wmfj; fhduq lrk iEu ,sms f,aLkhlu cd;sl yeඳුkqñm;a wxlh meyeos,sj" ksjerosj ,sùu w;HjYHfú' 3' ,smsf,aLKj, Pdhd msgm;a bosrsm;a lrk iEu úgu wdh;k m%Odkshd úiska tajd iy;sl l, hq;=fú' 4' iajdñmqreIhd " NdrAhdj" fofokdu rlaIs;hka kñ

w' ysñlñ m; frda.shdjq rlaIs;hdu bosrsm;a l, hq;=hs' wd' idudcslhdf.a orejka fjkqfjka ysñlñ b,a,qñ l, hq;= jkafka tla wfhl= muKs'

5' hefmkakka i|yd ysñlñ wh]ñm;a bosrsm;a lsrSfñoS my; f,aLk j, iy;sl l, cdhd msgm;a túh hq;=hs' rCIs;hd újdyl kï

w' l,;%hd i|yd - újdy iy;slfha Pdhd msgm;la wd' orejka i|yd - Wmamekak iy;slj, cdhd msgm;a ^orejd - jhi wjqreÿ 21 g wvq wújdyl /lshdjla fkdlrkafkl= úh hq;=hs&

rCIs;hd wújdyl kï

rCIs;hdf.a uj$mshd i|yd - ^uj$mshd - jhi wjqreÿ 70 g wvq úh hq;=hs&

• rCIs;hdf.a Wmamekak iy;slfha cdhd msgm;a • ujf.a $mshdf.a Wmamekak iy;slfha fyda cd;sl ye\kqïmf;a cdhd msgm;la • wújdyl nj oekaùug wdh;k m%Odkshdf.a ,smshla • ujg$mshdg ;ukaf.ka hefmk njg yd Tjqkag lsis\ wdodhï udrA.hla fkdue;s njg

.%du fiajd iy;slhla m%dfoaYSh f,alïf.a wkq w;aik iys;j

6' ysñlñ b,a,qñ lrk ldrKh i|yd fjk;a wdh;khlska rlaIK m%;s,dN ,nd we;s úg " fuu wdh;kfhkao m%;s,dN ,nd .ekSug wfmalaId lrkafka kñ tu wdh;kfha f.úï l, uqo, i|yka ,smshla iu. iy;sl lrk ,o ish,qu bkafjdhsisj,$ì,am;aj,$l=ú;dkaisj, Pdhd msgm;a bosrsm;a l, hq;=fú'

7' ksis mrsos iñmQrAK l, whÿñm; iu. my; i|yka ,sms f,aLK bosrsm;a l, hq;=fõ'

w' frday,a.;ùuloS fyda ie;aluloS$yDo ie;alulos$ms<sld frda. wdosh i|yd • frda. úksYaph ldûmf;a uq,a msgm; fyda iy;sl l< msgm;la

^ku" we;=,;ajq yd msgjq osk" m%;sldr l, ffjoHjrhdf.a w;aik ks, uq`j ;sìh hq;=h'& • fm!oa.,sl frday,l kñ ;ekam;a ,ÿm;a (Deposit receipts), uqo,a f.jq wjika ì,am; (Amount

Receipt) ,õia;rd;aul ì, (Final Bill ) " wfkl=;a ,ÿm;a yd bkafjdhsisj, uq,a msgm;a ^ku " oskh fjkia l, uq,q,a msgsgm;a fyda Pdhd msgsgm;a Ndr .kq fkd,efì'&

• fm!oa.,sl frday,a j,ska m%;sldr ,nd .ekSfïoS iEu jshoulau úia;rd;aulj ì,amf;a j¾. lr olajd ;sìh hq;=h' ffjoHjrhdf.a úhoï oelaúfïoS úfYaI{ ffjoHjrhdg yd wfkl=;a ffjoH jrekag l, úhoï fjkfjku oelaúh hq;=h

• fm!oa.,sl frday,l kñ whÿñmf;a m%Yak wxl ^11& ffjoHjrhdf.a iy;sl w;HjYHfõ' • yDo ie;aluloS " ie;alu isoq lsrSu i|yd ffjoHjrhd ksl=;a lrk ks¾foaY ,smsh'

wd' ore m%iQ;shloS ^wjia:d folloS muKla f.jkq ,efì& • by; ,shlshú,s j,g wu;rj orejdf.a Wmamekak iy;slfha iy;sl l, Pdhd msgm;la fyda Wm;a úia;r

m;%sldfú iy;sl l, msgm;la • rcfha frday,l frda. úksYaph ldûm; ,ndfkdfokafka kñ " .rANkS igyka jd¾;dfú iy;sl l< msgm;la

^frday,g we;=,;a l, oskh yd msgjq oskh i|yka jsh hq;=hs&

we' weia lKaKdû i|yd ^uq,a msgm;a ,nd osh hq;=hs'& - m%Yak wxl 3"4"7"11 msrúu wjYH fkdfú' • fm!oa.,sl ffjoHjrfhl= weia mrSCId lf,a kï ffjoHjrhd pek,a l< rsisám; yd jáfgdarej

^ffjoHjrhdf.a w;aik yd ks, uq`j ;sìh hq;=hs'& • rcfha frday,l weia mrSCId lf,a kñ jáfgdarej ^ffjoHjrhdf.a w;aik yd ks, uq`j ;sìh hq;=hs'& • lKaKdû i|yd uqo,a f.jq ,ÿmf;a “f.újd” f,i igyka lr wdh;kfha ks, uq`j ;sìh hq;=hs' ^wjqreoq

03lg jrla rCIs;hdg muKla f.jkq ,efì&

ksiss mrsoss iïmQ¾QK lrk ,o yssïlï whoqqïm; iu. wjYH ,smss f,aaLk tljr kssjerosj bosrssm;a lsrsfuka läkï w.%y%ydr rCIK m%;s,dN m%;smQraK lsrsu hgf;a m%udohlska f;drj m%;s,dN ,nd .; yels nj i,lkaak'