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 | r-ln -| i- | lili s- - | in| | 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.)
ii ili i li , DETAILS OF AMOUNT CLAIMED n -ni in| -i- NON HOSPITALISATION CASES ili AMOUNT IN Rs. Ps.
in| i i- -i
Patients Name & Relation i- i i- iili ini , |ii i i-
Doctors Name & Qualification / Tests Name i-i ni|i
Consultation Date i | i Cash Memo No
i-i i~
Consulta- tion charges
1 ;i ni i i~ Injection Administrat -ion fee 2
i i -~
Cost of Medicine
3 n |ii i~
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 li ni r, -n li r i - ii li n r | 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