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DK Kzy Egkys (KKDKJ Lkeku, Oa Lkekftd (Ks Ys (KK Ijh (KK ) E/ Izns'K) VKWFMV Hkou) Kalh JKSM) Xokfy J FPFDRLK O DH Izfriwfrz

1. This document is a medical expense reimbursement form for Ramakant Sharma who received treatment at BIMR Hospital in Bhopal. 2. It details the medicines purchased costing Rs. 613, consultation fees of Rs. 135 each, and other expenses of Rs. 1921, for a total claim of Rs. 2804. 3. The assistant medical officer and authorized medical practitioner have verified and signed the form, and the claimed medicines were checked against the approved list. The medical expenses of Rs. [amount] were approved for reimbursement.

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41 views

DK Kzy Egkys (KKDKJ Lkeku, Oa Lkekftd (Ks Ys (KK Ijh (KK ) E/ Izns'K) VKWFMV Hkou) Kalh JKSM) Xokfy J FPFDRLK O DH Izfriwfrz

1. This document is a medical expense reimbursement form for Ramakant Sharma who received treatment at BIMR Hospital in Bhopal. 2. It details the medicines purchased costing Rs. 613, consultation fees of Rs. 135 each, and other expenses of Rs. 1921, for a total claim of Rs. 2804. 3. The assistant medical officer and authorized medical practitioner have verified and signed the form, and the claimed medicines were checked against the approved list. The medical expenses of Rs. [amount] were approved for reimbursement.

Uploaded by

max
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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dk;kZy; egkys[kkdkj ¼lkekU; ,oa lkekftd {ks= ys[kk ijh{kk½] e/;

izns'k] vkWfMV Hkou] >kalh jksM] Xokfy;j


fpfdRlk O;; dh izfriwfrZ
1- uke rFkk inuke fodkl flag] 02@10852
2- fuokl dk lgh irk Q.NO. 499/T-III SHASTRI NAGAR
3- jksxh dk uke vkSj laca/k jkek “kadj flag] firk
5- fpfdRlk dgka gqbZ ch- vkbZ- ,e- vkj- vLikry] Xokfy;j
6- izdj.k ds fpfdRlk vf/kdkjh ¼izkf/kd`r fpfdRlk ifjpkyd dk uke½
DR. SUSHIL SHARMA & DR. AKASH MODI
7- vifjgk;Zrk izek.k i= esa vuq'kalk dh xbZ vkS"kf/k;ka&
Ø- nok HkaMkj iphZ dk Ø- o vkiwfrZ nok ds uke dher
l- dk uke fnukad dk ¼:-½
fnukad
TRUST MEDICAL TF002413/16.05.18 16.05.18
1. ROZUCOR ASP CAP 20 123
STORE

CARCA CR 20MG 250

DOXOVENT TAB 41
400MG

CTD T 12.5/40 TAB


227.33
CYRA D CAP
80
TOTAL
613

8- [kjhnh xbZ nokb;ksa dh dher :- 613


ijke'kZ 'kqYd :-135+$135
bUtsD'ku yxkbZ 'kqYd &fujad
vU; O;; 1921
9- nkok dh xbZ dqy jkf'k :- 2804
10- 'kkldh; deZpkjh ds gLrk{kj
11- vLohd`fr jkf'k mlds dkj.kksa lfgr
12- fuoy ikfjr jkf'k

vifjgk;Zrk izek.k i= Ø- d@[k lgk;d fpfdRlk vf/kdkjh@lgk;d ckg~;


fpfdRlk foHkkx ds fpfdRlk vf/kdkjh LVkai ------------------------------------------
------------------------------------------------------------------------------------------------
ds vkosnu dk izdj.k ds izdj.k ds izHkkjh fpfdRlk vf/kdkjh us uxnh ifpZ;ksa
dk lR;kiu fd;k gS rFkk izf/kd`r fpfdRlk ifjpkjd us izfrgLrk{kj fd, gSA
vifjgk;Zrk izek.k i= esa fu.kZ; vkS"kf/k;ksa dh tkap vkS"kf/k lwph ls dj yh
xbZ gS] ,slh vkS"kf/k;kas dh tkap dj ewY; lfEefyr ugha fd;k x;k gS tks fd
izfriwfrZ ;ksX; ugha gSA
Jh---------------------------------------------------------------------------------------------
---------------------------------------------------------}kjk izLrqr fd;k x;k nkok
O;ofLFkr :i esa gSA
fpfdRlk O;; :i;s----------------------------------------------------------¼:i;s-----
------------------------------------------------------------------------------------------------
-----------------------½ dh izfriwfrZ Lohd`r dh tkrh gSA

lgk;d ys[kk ijh{kk vf/kdkjh


Lohd`r
ofj"B ys[kkijh{kk vf/kdkjh

mi egkys[kkdkj
¼iz'kklu½

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