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Remid Payments

Mid examination aspects

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piduguhareesh115
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23 views

Remid Payments

Mid examination aspects

Uploaded by

piduguhareesh115
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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APPLICATION FORM FOR CLAIMING REIMBURSEMENT OF MEDICAL EXPENSES

1.a.Name of the Employee: ______________________________________


(CAPITAL LETTERS)
b.Designation: __________ c.ICNo.:________ d.Section:________
e.Unit: __________ f.Ph.No.:_______ g.Basic pay:Rs.___
h.Residential address:________________________________________
i.Whether spouse is also working ? : Yes / No
If yes, Name: Designation:
Pay:Rs. ICNo.: Dept./Unit:

2.a.Name of the patient: ________________________________________


b.Age: _____ c.Medical card No.:___________ d.Relationship:____
to employee
3.a.Name of the Hospital/Centre/Lab/ : __________________________
Specialist and address to which
the patient referred for __________________________

* b.Referral letter dated : ______________


c.Nature of treatment / period : __________________________

4.a.In case of Chennai beneficiary furnish


Authorised Medical Attendant consulted:______________________
b.Registration No. :_____________
c.Clinic address :______________________
d.Date(s) of consultation :______________________

5. If this claim is for reimbursement of


expenses like orthopaedic appliances
etc., indicate whether any
reimbursement obtained earlier ? : Yes / No
If yes, a.Name of the item purchased :

b.Date of purchase: c.Amount reimbursed:Rs.

6. Details of the bill(s) enclosed with the claim:


-----------------------------------------------------------------
S.No. Bill No. Date Amount Particulars
-----------------------------------------------------------------

-----------------------------------------------------------------

7. Total amount : Rs.


8. Advance drawn, if any : Rs.
9. Advance amount refunded, if any : Rs.
10. Balance amount claimed : Rs.

Date: Signature

(*NOTE: A copy of referral letter is to be enclosed with this claim)


To
CHSS OFFICE, DAE Hospital, Kalpakkam 603 102.

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