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Medical Charges Reimbursement Form: Item Names Charges Details of Cash-Memos Etc

This document appears to be a medical charges reimbursement form used by employees of an office to claim reimbursement for medical expenses incurred for themselves or their dependents. The form requests information such as the claimant's name and designation, patient name and relationship to claimant, period of illness, itemized list of treatment charges with details, total claim amount, advance drawn against claim, net payable amount, and verification by a medical officer. Instructions at the bottom specify listing medicines and tests individually, attaching cash receipts, and mentioning hospital admission and stay dates.

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Amit Kumar
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1K views

Medical Charges Reimbursement Form: Item Names Charges Details of Cash-Memos Etc

This document appears to be a medical charges reimbursement form used by employees of an office to claim reimbursement for medical expenses incurred for themselves or their dependents. The form requests information such as the claimant's name and designation, patient name and relationship to claimant, period of illness, itemized list of treatment charges with details, total claim amount, advance drawn against claim, net payable amount, and verification by a medical officer. Instructions at the bottom specify listing medicines and tests individually, attaching cash receipts, and mentioning hospital admission and stay dates.

Uploaded by

Amit Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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H.P.T.R.

MEDICAL CHARGES REIMBURSEMENT FORM


1. Name and Designation
2. Office in which Employed
3. Basic Pay
4. Name of Patient & relation with
the Claimant
5. Period of Illness
6. PARTICULARS OF TREATMENT:
Item Names Charges Details of Cash-Memos etc.
(i) Medicines (Names)

P.T.O.
(ii) Laboratory Tests/Ambulance/Consultancy/Indoor Room/Others (Specify)

6. Total Claim ₹.......................................

7. Less—Advance Drawn vide T/V

No.......................................Dt.......................................₹........................................

8. Net Amount Payable ₹.......................................

I hereby declare that the statemerits in this application are true to the best of my knowledge and belief and
that the person for whom medical expenses were incurred is wholly dependent on me.

Date.................................. (Signature of the Claimant)

VERIFICATION CERTIFICATE

I, Dr...................................................................hereby certify that......................................................................


suffering from.........................................................and is/was under my treatment from............................................
to.....................................and that the above mentioned medicines/tests were prescribed by me in this connection.
The claim is verified for ₹.......................................

Date............................. (Signature of Medical Officer)


Designation & Seal
Passed for ₹........................................ (Rupees.......................................................................................................)

and included in Bill No...............................................Dated.......................................................

(Signature of Controlling Officer) (Signature of the DDO)

INSTRUCTIONS

1. List all the medicines, tests etc. individually.


2. Attach Cash-Memos duly verified.
3. Mention dates of admission to the Hospital, Stay etc.

राजकीय मुद्रणालय, हिमाचल प्रदे श, शशमला - सी. पी. एण्ड एस. / 2009—25—2—2009 — 2,00,000.

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