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Medical Charges Reimbursement Form Bhaskar Mahajan/ Head Constable No. 95 O/O S.P. Chamba, Police Line Chamba Rs. 13900/-Self. 18/09/2013 To Onwards

1. This is a medical charges reimbursement form submitted by Bhaskar Mahajan, a head constable, for treatment received from August 9, 2023 to October 30, 2023. 2. It details medicines, laboratory tests, and other medical expenses totaling Rs. 9,295.49 incurred during his illness and treatment. 3. The form requires verification from the treating physician and controlling officer before reimbursement of the net amount of Rs. 9,295.49.

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agnymahajan
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26 views

Medical Charges Reimbursement Form Bhaskar Mahajan/ Head Constable No. 95 O/O S.P. Chamba, Police Line Chamba Rs. 13900/-Self. 18/09/2013 To Onwards

1. This is a medical charges reimbursement form submitted by Bhaskar Mahajan, a head constable, for treatment received from August 9, 2023 to October 30, 2023. 2. It details medicines, laboratory tests, and other medical expenses totaling Rs. 9,295.49 incurred during his illness and treatment. 3. The form requires verification from the treating physician and controlling officer before reimbursement of the net amount of Rs. 9,295.49.

Uploaded by

agnymahajan
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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H.P.T.R.

6
MEDICAL CHARGES REIMBURSEMENT FORM
1. Name and Designation BHASKAR MAHAJAN/ HEAD CONSTABLE NO. 95
2. Office in which Employed O/O S.P. Chamba, Po!"# L!$# Chamba
3. asic Pay R%. &'9((/)
!. Name of Patient " #elation with the $laimant S#*.
%. Pe#iod of &llness &+/(9/,(&' -o o$.a/0%
6. P'RT&$()'R* O+ TRE'T,ENT-
I-#m Nam#% Cha/1#% D#-a!% o* Ca%h)M#mo% #-".
.i/ ,edicines .Names/
1. $hlo#o01ine Ta2 36.41 5ide cash memo no. 13637832944 dated
2. :one 1gm &n; 231.4! 14.37.2313 f#om <an '1shadi Rogi =alyan
*amiti6D.R.P.>.,.$. " H. =ang#a at Tanda
TOTAL ,(9.((
.ii/ )a2o#ato#y Tests8'm21lance8$ons1ltancy8&ndoo# Room8 Othe# .*pecify/
1. Diffe#ential )e1cocyte $o1nt 13.33 5ide ill &D627%49% Dated 14.37.13
2. Total )e1?ocyte $o1nt 13.33 6Do6
3. *e#1m >l1cose 33.33 6Do6
!. Renal +1nction Test 63.33 6Do6
%. Haemoglo2in %.33 6Do6
6. *e#1m *odi1m 33.33 6Do6
9. *e#1m Potassi1m 33.33 6Do6
4. Platelets 13.33 6Do6
7. *e#1m P#otein 33.33 5ide ill &D627619! Dated 14.37.13
13. Pe#iphe#al lood *mea# 13.33 6Do6
11. lood (#ea Nit#ogen 33.33 6Do6
12. @eil +eliA 3%.33 6Do6
13. (#ine $1lt1#e %3.33 6Do6
1!. Retic1locyte $o1nt 13.33 6Do6
1%. )iBe# +1nction Tests 123.33 6Do6
16. *e#1m $alci1m 33.33 6Do6
19. (#ine Ro1tine EAamination 33.33 6Do6
14. E#yth#ocyte *edimentation Rate 13.33 6Do6
17. Red lood $ell 13.33 6Do6
23. lood $1lt1#e and *ensitiBity 133.33 6Do6
21. Platelets 13.33 6Do6
22. @idal Test 3%.33 6Do6
TOTAL 295.((
9. Total $laim Rs.,(9329549(5
4. )essC'dBance D#awn Bide T85
NoDDDDDD.DtDDDDDD..RsDDDDDDD..
7. Net 'mo1nt Paya2le R%. 9(5/)
& he#e2y decla#e that the statements in this application a#e t#1e to the 2est of my ?nowledge an
2elief and that the pe#son fo# whom medical eApenses we#e inc1##ed is wholly dependent on me.
DateDDDDDD.. .*ignat1#e of $laimant/
6ERIFICATION CERTIFICATE
&E D#. DDDDDDDDDDDDDDDD.he#e2y ce#tify that Bha%7a/ Maha8a$ s1ffe#ing f#om
DDDDDDDDDDDDDDDand is8was 1nde# my t#eatment f#om &+.(9.&' to o$.a/0% and that the
a2oBe mentioned medicines8tests we#e p#esc#i2ed 2y me in this connection.
The claim is Be#ified fo# Rs. 9(5/)
DateDDDDDD. 9S!1$a-:/# o* M#0!"a O**!"#/;
D#%!1$a-!o$ < S#a
Passed fo# Rs. DDDDDDD..R1peesDDDDDDDDDDDDDDDDDDDDDDDDD/
and incl1ded in ill no. DDDDDDDDDDDDated DDDDDDDDDDDDD
.*ignat1#e of $ont#olling Office#/ .*ignat1#e of DDO/
INSTRUCTIONS
1. )ist all the medicinesE tests etc. indiBid1ally.
2. 'ttach $ash6,emos d1ly Be#ified.
3. ,ention dates of admission to the HospitalE *tay etc.

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