Medical Charges Reimbursement Form 635e1i

H.P.T.R.6

Medical Charges Reimbursement Form 1. Name and Designation

:

SUNDER LAL, Cook Retd.

2. Office in which Employed

:

H.P.P.W.D. B& R (AE, Sub Division No. 1)

3. Basic Pay

:

6200/-

4. Name of Patient & Relation

:

Self

5. Period of Illness

:

19.09.13 to 30.11.13

6. Particulars of Treatment :

SN Item Names 30 Cap Ecosprin 30 Tab Telzy40 30 Cap Lynco I 30 Cap PD Star 30 Tab Boncal 30 Tab Mathacfa 30 Cap Ecosprin 30 Tab Telzy40 30 Cap Lynco I 30 Cap PD Star 30 Tab Boncal 30 Tab Mathacfa 1 Amp Emesct 1 Vail Panzel 2 Nos syninze 5 ml 30 Cap Ecosprin 30 Tab Telzy40 30 Cap Lynco I 30 Cap PD Star 30 Tab Boncal 30 Tab Mathacfa 30 Cap Evion - 600

Charges Details of Cash- Memos etc. 62.40 196.50 Cash Memo no. 7535 dated 269.70 19.09.2013, Jhina Medical 216.00 Store Solan (H.P.) 264.00 297.00 Bill Total 1305.60 62.40 196.50 269.70 Cash Memo no. 9531 dated 216.00 30.10.13, Jhina Medical Store 264.00 Solan (H.P.) 297.00 15.50 59.00 10.00 Bill Total 1390.10 62.40 208.50 Cash Memo no. 10462 dated 269.70 30.11.13, Jhina Medical Store Solan (H.P.) 216.00 264.00 297.00 73.20 Bill Total 1390.80 Grand Total

7. Total Claim

4086.50

Rs. 4086 (Four Thousand Eighty Six Only)

8. Less Advance Drawn Vide T/V No. _________ Drt._______ 9. Net amount payable

Rs. Rs. 4086 (Four Thousand Eighty Six Only)

I hereby declare that the statements 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 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 Rs. ____________________

Date :_______________________

(Signature of Medical Officer) Designation & Seal

-----------------------------------------------------------------------------------------------------------------------------ed for Rs. ________________________ (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 ission to the Hospital, stay etc.

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