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)
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
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.