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    Medical Reimbursement Claim - Indoor

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    jinto
    The document is a medical reimbursement claim form that contains sections for an employee to provide their name, designation, patient name and relationship, nature of illness, treating doctor/hospital, period of treatment, and a breakdown of expenses including consultation fees, diagnostics, medicines, appliances, room rent, nursing charges, and others. The employee must sign a declaration that the information provided is true to the best of their knowledge.

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    Medical Reimbursement Claim - Indoor

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    jinto
    64 views1 page
    The document is a medical reimbursement claim form that contains sections for an employee to provide their name, designation, patient name and relationship, nature of illness, treating doctor/hospital, period of treatment, and a breakdown of expenses including consultation fees, diagnostics, medicines, appliances, room rent, nursing charges, and others. The employee must sign a declaration that the information provided is true to the best of their knowledge.

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    Medical Reimbursement claim - Indoor

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    The document is a medical reimbursement claim form that contains sections for an employee to provide their name, designation, patient name and relationship, nature of illness, treating doctor/hospital, period of treatment, and a breakdown of expenses including consultation fees, diagnostics, medicines, appliances, room rent, nursing charges, and others. The employee must sign a declaration that the information provided is true to the best of their knowledge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    64 views1 page

    Medical Reimbursement Claim - Indoor

    Uploaded by

    jinto
    The document is a medical reimbursement claim form that contains sections for an employee to provide their name, designation, patient name and relationship, nature of illness, treating doctor/hospital, period of treatment, and a breakdown of expenses including consultation fees, diagnostics, medicines, appliances, room rent, nursing charges, and others. The employee must sign a declaration that the information provided is true to the best of their knowledge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    ANNEXURE – D

    MEDICAL REIMBURSEMENT CLAIM FORM FOR INDOOR


    TREATMENT
    1. Name of Employee:
    2. Designation:
    3. Reg. No.:
    4. Salary (Basic Pay + DA)/Pension (as on 01-04--------):
    5. Place of Duty:
    6. Name of Patient:
    7. Relationship with Employee:
    8. Age:
    9. Nature of illness:
    10. Name of Doctor/Hospital:
    11. Period of treatment: From ------------- To--------------------
    (Certificate issued by the Medical Officer in-charge of the hospital as per
    enclosed proforma is to be attached)
    12. Details of claim:
    (attach prescription, vouchers, etc. in duplicate)
    ________________________________________________________________________
    _
    Voucher No. Amount
    • Consultation:
    • Diagnostics/Tests:
    • Medicines/Injections:
    • Appliances:
    • Room Rent:
    • Charges for Nurses:
    • Others:
    ___________________
    Total:
    (Rupees-------------------------------------------------------)
    Declaration:
    I, hereby declare that the statements given in application are true to the best of my
    knowledge and belief and that the person for which medical expenses are incurred is
    fully dependent on me.

    (Signature of Employee)

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