Esic - mother is admitted in private hospital - can I apply for reimbursement?

I come under ESIC. My mother is admitted to a private hospital due to some emergency. Please let me know if I can apply for reimbursement from ESIC.

Below is the URL for ESIC reimbursement:
[Reimbursement](http://www.esic.nic.in/reimbursement)

Could someone please forward Section 17(2) IT Act form, please? I am unable to find it on the internet.

Thanks

Application format for IP reimbursement of medical bills along with the reason for not attending ESIC hospital for an emergency certificate.

Thank you for providing the information. Please find below the corrected and properly formatted text:

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Application format for IP reimbursement of medical bills along with the reason for not attending ESIC hospital for an emergency certificate.