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CLAIM FOR MEDICAL REIMBURSEMENT


NON - HOSPITALISATION

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Mode of Payment : Cash/Chque


i| i/ DIARY NO.
iln ni|i/ DATE RECEIVED.
||
C.C
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VR-NO.
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VR-Date
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SC NA

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Project
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Deptt.
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Name of Employee
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Claim Date
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Emp. No. + CKD
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Claim amount
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Employees Name Designation ..
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Basic Pay Deptt. .. Rax No.
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Bank Name . Bank Account No.
(~iii liin ,ii i i l , To be filled by Accounts Deptt.)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (ii - ) i ii inni rn -|n
Claim passed for payment for Rupees (in words) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Account Code
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Amount
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Cash bank Code
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Mode
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Cheque No.

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Acctt. AO/ Sr. A.O Manager (F)
i | ni|i/Cheque Date
i. . . . . . . . . . . . . . . . . . . . . . . . (ii -) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in l

Received Rs .. Rupees (in words)
...
li / Date :
l-i| / Note : -i| r-nii
1. i| -i-i - ll- i - -i nii | | Sign. Of the Employee
Doctors prescription & cash memo in original should be attached in all cases.
2. ii ilii | | | Receipts for the amounts claimed should be enclosed.
3. lnln i l-i - s - rn i .raa, | ii| n liinii , .aaa, | ii| n -ri i (-i
l) | i .aaa, li | ii| li (il-) r-nii i | i n| r | l-n liin
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Signature of the HOD to reimbursement if claim is in relation of rules and amount involved is up to Rs 500/-, GM
(HRM ), if amount involved is up to Rs. 1000/-, D (P), if amount involved is more than Rs 1000/- Relaxation is to be
approved in consultation of Finance and recommendation of company Doctor
- i r n -i| ,ii ii i/SL NO.1 TO 5 TO BE FILLED BY THE EMPLOYEE
( ii liin ,ii i - i| i i -ii r | )
(To be detached and sent back to the employee by Accounts Deptt.)

1. i- / Name .. 2. -i| i / Employee No.
3. liin/ Deptt. . 4. ii ni|i / Claim Date
5. ./For Rs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l
6. . . . . . . . . . . . . -|n . . . . . . . . . . i . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - -i l n |
Passed for Rs . . . . . . . . . . . and credited to . . . . . . . . . . . . . . . . . . . . . . . . . . Bank on . . . . . . . . . . . .
(-ilni l |s i /For deductions please see overleaf)
0.00
0.00

ii ili i li , DETAILS OF AMOUNT CLAIMED
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NON HOSPITALISATION CASES
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AMOUNT IN Rs. Ps.

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Patients Name &
Relation
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Doctors Name
& Qualification
/ Tests Name
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Consultation
Date
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|
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Cash
Memo
No

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Consulta-
tion charges

1
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Injection
Administrat
-ion fee
2

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Cost of
Medicine

3
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Pathologi-
cal test
charges
4

i / Sub Total

i n / TOTAL 1+2+3+4 i - / in Rs ( ii - , in words)
) -i/only
i-ilin li ini r l ri n - | ii| li r l ;
i - l~lin li - r nii l lni ll-i
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Certified that the particulars mentioned in this claim are true to best
of my knowledge and belief and that the person for whom, medical
expenses were incurred is wholly dependent upon me and residing
with me. li lii| i-
-i r ii r-nii
-i| r-nii,Signature of Employee : Signature of the Controlling
ni|i/ Date : officer with designation & stamp
-| n ili i li , DETAILS OF AMOUNT DISALLOWED
ii/Reasons ili/Amount
1.
2.
3. . .. . ~iii lii|,l li
4. .. . . A.O/ Sr. A.O

0.00 0.00 0.00 0.00
0.00