Medical Bill for Blank (1)

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ANNEXURE C MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT 1 2 3 4 5 6 7 8 9 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2010) Place of Duty: Name of Patient: Relationship with Employee: Age: Reimbursement claimed under: Treatment from RMP (as per para 2.1.2) O/O SDE NIB-III MHS Bhavan, 2nd Floor Pune-411001. HRMS No. Staff No.

10 Nature of illness: 11 Name of Doctor / Hospital:

12 Detail of claim: (Attach prescription, vouchers etc. in duplicate) Sl. Particulars No . a Consultation: b d e f g Medicines Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1) Same as a (1st entry) Particulars (Rupees: . ) 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 wholly dependent on me. Total Rounded Vouchers Detail Particulars No. Date Amount

(Signature of Employee)

1

ANNEXURE C

MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 7 8 9 10 11 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2012) Place of Duty: Name of Patient: Relationship with Employee: Age: Reimbursement claimed under: Nature of illness: Name of Doctor / Hospital: Katke Subhash Kisan Telephone Mechanic 4670 (Basic Pay = ) Rs. 17,490 /- + DA as admissible on date SDE (NIB) MHS Bhavan Pune-1 Subhash Kisan Katke Self 55 years. Treatment from RMP (as per para 2.1.2) Oral Infection Dr Kalyani Bhatia Jehangir Hospital 32 Sasoon Road Pune-1 Staff No. 27041

12 Sl. No. a

Detail of claim: (Attach prescription, vouchers etc. in duplicate) Particulars Particulars Consultation:

Vouchers Detail No. 31 Date 07/04/2005.

Amount

OPD Consulting charges

60.00

b

Diagnostics/Tests:

-

-

c

Medicines

Sancheti Chemist Daulat Medical & Gen. Stores

2494 10352

07/04/2005. 07/04/2005.

24.00 41.20

d e f g

Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1) Same as a (1st entry) Total Say 125.20 125.00

(Rupees: One hundred twenty five only) 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 wholly dependent on me.

(Signature of Employee)

ANNEXURE C MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 7 8 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: Relationship with Employee: Age: Rajendra A. Wable J.T.O. (Civil) Staff No. D 05453

(Basic Pay = ) Rs. 10,850 /- + DA as admissible on date Hadapsar ,Pune. Mrs. Ujwala R. Wable. Wife 33 Years

9 Reimbursement claimed under: 10 Nature of illness: 11 Name of Doctor / Hospital:

Treatment from RMP (as per para 2.1.2) Chest pain Dr.Ajit Khot Scheme 3, Plot No.57,Sector 21,Yamunanagar,Nigdi,Pune-44.

12 Detail of claim: (Attach prescription, vouchers etc. in duplicate) Sl. Particulars No. a Consultation: b c d e f g Diagnostics/Tests: Medicines Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1)

Vouchers Detail Particulars No. OPD Consulting charges Akshada Medico & General Stores Same as a (1st entry) 717

Amount Date

07/04/05 95.40

Total 95.40 Say 95.00 (Rupees: Ninty Five only) 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 wholly dependent on me.

-

-

(Signature of Employee)

2

ANNEXURE C

MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 7 8 9 10 11 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: Relationship with Employee: Age: Reimbursement claimed under: Nature of illness: Name of Doctor / Hospital: Katke Subhash Kisan Telephone Mechanic 4670 (Basic Pay = ) Rs. 17,490 /- + DA as admissible on date SDE (NIB) MHS Bhavan Pune-1 Subhash Kisan Katke Self 55 years. Treatment from RMP (as per para 2.1.2) Oral Infection Dr Kalyani Bhatia and Dr Sanjay Agarwal Jehangir Hospital 32 Sasoon Road Pune-1 Staff No. 27041

12 Sl. No. a

Detail of claim: (Attach prescription, vouchers etc. in duplicate) Particulars Particulars Consultation:

Vouchers Detail No. 141812 Date 23/10/2012 OPD Consulting charges

Amount 350.00

b

Medicines

Jehangir hospital Medical store Jehangir hospital Medical store Jehangir hospital Medical store

49437 55057 55851

29/09/12 20/10/2012 23/10/2012

232.00 272.00 282.00

-

g

Claim w/o voucher: (as per Para 2.1.1)

Same as a (1st entry) -

Total -

1136.00

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 wholly dependent on me.

(Signature of Employee) 3

ANNEXURE C

MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: (Basic Pay = ) Rs. 17,490 /- + DA as admissible on date SDE (NIB) MHS Bhavan Pune-1 Katke Subhash Kisan Telephone Mechanic 4670 Staff No. 27041

7 8 9 10 11

Relationship with Employee: Age: Reimbursement claimed under: Nature of illness: Name of Doctor / Hospital:

Wife 33 Years Treatment from RMP (as per para 2.1.2) Premenstrual Syndrome Dr.( Mrs.) K. A. Rao THEMI TERRACE,Palia Estate,44/2,SASOON ROAD,Near Ruby Hall,Opp. Wadia College,Pune-411 001.

12 Sl. No. a

Detail of claim: (Attach prescription, vouchers etc. in duplicate) Particulars Particulars Consultation:

Vouchers Detail No. Date OPD Consulting charges

Amount

b

Diagnostics/Tests:

USG Jehangir Hospital,Sasoon road

14139

02/07/2005

255.00

c

Medicines

Shraddha Medical & General Stores

2220

02/07/2005

32.70

d e f g

Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1) Same as a (1st entry) Total Say 287.70

(Rupees: Two hundred Eighty Seven only) 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 wholly dependent on me.

(Signature of Employee) 4

ANNEXURE C

MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 7 8 9 10 11 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: Relationship with Employee: Age: Reimbursement claimed under: Nature of illness: Name of Doctor / Hospital: (Basic Pay = ) Rs. 10,850 /- + DA as admissible on date Hadapsar ,Pune. Himanshu R. Wable. Son 7 Years Treatment from RMP (as per para 2.1.2) Viral Fever & Cold Dr. Jayant Joshi Flat No. 3 , Mohanwadi,Near Sathe Biscuit Bridge,Yerwada,Pune-411 006. Rajendra A. Wable J.T.O. (Civil) Staff No. D 05453

12 Sl. No. a

Detail of claim: (Attach prescription, vouchers etc. in duplicate) Particulars Particulars Consultation:

Vouchers Detail No. 9234 Date 27/06/2005 OPD Consulting charges

Amount 120.00

b

Diagnostics/Tests:

c

Medicines

Shraddha Medical & General Stores

2143

26/06/2005

46.10

d e f g

Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1) Same as a (1st entry) Total Say 166.10 166.00

(Rupees: One hundred Sixty Six only) 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 wholly dependent on me.

(Signature of Employee)

6

ANNEXURE C

MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 7 8 9 10 11 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: Relationship with Employee: Age: Reimbursement claimed under: Nature of illness: Name of Doctor / Hospital: (Basic Pay = ) Rs. 10,850 /- + DA as admissible on date Hadapsar ,Pune. Mrs. Ujwala R. Wable. Wife 33 Years Treatment from RMP (as per para 2.1.2) Backache Dr. Suhas Bulbule Pratiknagar, Shop No. 2 , Building No. 4, Yerwada, 006. Pune-411 Rajendra A. Wable J.T.O. (Civil) Staff No. D 05453

12 Sl. No. a

Detail of claim: (Attach prescription, vouchers etc. in duplicate) Particulars Particulars Consultation:

Vouchers Detail No. Date

Amount

OPD Consulting charges

b

Diagnostics/Tests:

c

Medicines

Novelty Medical & General Stores

3543

15/04/2005

135.65

d e f

Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: -

g

Claim w/o voucher: (as per Para 2.1.1)

Same as a (1st entry) -

Total

-

135.65 Say 136.00

(Rupees: One hundred Thirty Six only) 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 wholly dependent on me.

(Signature of Employee) 7

ANNEXURE C MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 7 8 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: Relationship with Employee: Age: (Basic Pay = ) Rs. 10,850 /- + DA as admissible on date Hadapsar ,Pune. Himanshu R. Wable. Son 7 Years Treatment from RMP (as per para 2.1.2) Cough & Cold Dr. Suhas Bulbule Pratiknagar, Shop No. 2 , Building No. 4, Yerwada, 411 006. Rajendra A. Wable J.T.O. (Civil) Staff No. D 05453

9 Reimbursement claimed under: 10 Nature of illness: 11 Name of Doctor / Hospital:

Pune-

12 Detail of claim: (Attach prescription, vouchers etc. in duplicate) Sl. Particulars No. a b c d e f g Consultation: Diagnostics/Tests: Medicines Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1)

Vouchers Detail Particulars No. OPD Consulting charges

Amount Date

Novelty Medical & General Stores Same as a (1st entry) -

14790

30/07/2005

60.80

Total

Say

60.80 61.00

(Rupees: Sixty one only) 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 wholly dependent on me.

(Signature of Employee)
8

ANNEXURE C

MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 7 8 9 10 11 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: Relationship with Employee: Age: Reimbursement claimed under: Nature of illness: Name of Doctor / Hospital: (Basic Pay = ) Rs. 10,850 /- + DA as admissible on date Hadapsar ,Pune. Rajendra A. Wable. Self 37 years. Treatment from RMP (as per para 2.1.2) High B. P. Dr. Suhas Bulbule Pratiknagar, Shop No. 2 , Building No. 4, Yerwada, 006. Rajendra A. Wable J.T.O. (Civil) Staff No. D 05453

Pune-411

12 Sl. No. a

Detail of claim: (Attach prescription, vouchers etc. in duplicate) Particulars Particulars Consultation:

Vouchers Detail No. Date OPD Consulting charges

Amount

b

Diagnostics/Tests:

-

-

c

Medicines

Novelty Medical & General Stores

14788

30/07/2005

104.40

d e f g

Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1) Same as a (1st entry) Total Say 104.40 104.00

(Rupees: One hundred and four only) 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 wholly dependent on me.

(Signature of Employee) 9

ANNEXURE C

MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT
1 2 3 4 5 6 7 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: Relationship with Employee: (Basic Pay = ) Rs. 10,850 /- + DA as admissible on date Hadapsar ,Pune. Himanshu R. Wable. Son Rajendra A. Wable J.T.O. (Civil) Staff No. D 05453

8

Age:

7 Years Treatment from RMP (as per para 2.1.2) Viral Fever & Cold Dr. Ravindra Kadam SHAKUN CLINIC, Behind Nigdi Bus stop, Nigdi,Pune- 411 044.

9 Reimbursement claimed under: 10 Nature of illness: 11 Name of Doctor / Hospital:

12 Detail of claim: (Attach prescription, vouchers etc. in duplicate) Sl. Particulars No. a b c Consultation: Diagnostics/Tests: Medicines

Vouchers Detail Particulars No. OPD Consulting charges 563 573

Amount Date 21/06/2005 21/06/2005 80.00 60.00

Kiran Medical & General store Sancheti Chemist

11340 2813

21/06/2005 25/06/2005

44.20 149.55

d e f g

Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1) Same as a (1st entry) Total 333.75

Say 334.00 (Rupees: Three hundred and Thirty Four only) 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 wholly dependent on me.

(Signature of Employee)
10

ANNEXURE C MEDICAL REIMBURSEMENT CLAIM FOR OUTDOOR TREATMENT 1 2 3 4 5 6 7 8 Name of Employee Designation: Reg. No.: Salary (Basic Pay + DA) (as on 01.04.2005) Place of Duty: Name of Patient: Relationship with Employee: Age: (Basic Pay = ) Rs. 10,850 /- + DA as admissible on date Hadapsar ,Pune. Mrs. Ujwala R. Wable. Wife 33 Years Treatment from RMP (as per para 2.1.2) Premenstrual Syndrome Dr.( Mrs.) Asha V. Bajaj Mamta Maternity & Nursing Home, 25,111/1, Alandi road, Pune411 006. Rajendra A. Wable J.T.O. (Civil) Staff No. D 05453

9 Reimbursement claimed under: 10 Nature of illness: 11 Name of Doctor / Hospital:

12 Detail of claim: (Attach prescription, vouchers etc. in duplicate) Sl. Particulars No.

Vouchers Detail

Amount

Sl. Particulars No. a b c d e f g Consultation: Diagnostics/Tests: Medicines Appliances: Special treatment (e.g. Physiotherapy, Yoga etc.) Others: Claim w/o voucher: (as per Para 2.1.1)

Amount Particulars OPD Consulting charges Novelty Medicals & General Stores Same as a (1st entry) Total 193.00 14808 01/08/2005 193.00 No. Date

Say 193.00 (Rupees: One hundred ninty three only) 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 wholly dependent on me.

(Signature of Employee) 11

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