Scribd Logo
Upload

Welcome to Scribd!

  • 54 views

    Medical Reimbursement Claim Form For Outdoor Treatment: Attach Prescription, Vouchers)

    Uploaded by

    balaji
    This document is a medical reimbursement claim form submitted by R J BALASUBRAMANYAM, a JTO at CTTC Jammu. The claim is for outdoor treatment of R J BALASUBRAMANYAM himself from Dr. Jagmeet Kour between May 30th and July 12th, 2017. The total claim amount is Rs. 10,342 which includes consultations and medicines purchased over that period as evidenced by attached vouchers. R J BALASUBRAMANYAM declares the information provided is true to the best of his knowledge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Reimbursement Claim Form For Outdoor Treatment: Attach Prescription, Vouchers)

    Uploaded by

    balaji
    54 views2 pages
    This document is a medical reimbursement claim form submitted by R J BALASUBRAMANYAM, a JTO at CTTC Jammu. The claim is for outdoor treatment of R J BALASUBRAMANYAM himself from Dr. Jagmeet Kour between May 30th and July 12th, 2017. The total claim amount is Rs. 10,342 which includes consultations and medicines purchased over that period as evidenced by attached vouchers. R J BALASUBRAMANYAM declares the information provided is true to the best of his knowledge.

    Original Description:

    claim

    Original Title

    Zhrf Claim Outdoor

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a medical reimbursement claim form submitted by R J BALASUBRAMANYAM, a JTO at CTTC Jammu. The claim is for outdoor treatment of R J BALASUBRAMANYAM himself from Dr. Jagmeet Kour between May 30th and July 12th, 2017. The total claim amount is Rs. 10,342 which includes consultations and medicines purchased over that period as evidenced by attached vouchers. R J BALASUBRAMANYAM declares the information provided is true to the best of his knowledge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    54 views2 pages

    Medical Reimbursement Claim Form For Outdoor Treatment: Attach Prescription, Vouchers)

    Uploaded by

    balaji
    This document is a medical reimbursement claim form submitted by R J BALASUBRAMANYAM, a JTO at CTTC Jammu. The claim is for outdoor treatment of R J BALASUBRAMANYAM himself from Dr. Jagmeet Kour between May 30th and July 12th, 2017. The total claim amount is Rs. 10,342 which includes consultations and medicines purchased over that period as evidenced by attached vouchers. R J BALASUBRAMANYAM declares the information provided is true to the best of his knowledge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    Medical Reimbursement Claim Form For Outdoor Treatment

    Annexure - C to ( Order Dt. 22 April 2003 )

    Claim Number 00000000000002023741 Personnel Number 01100413

    1. Name Of Employee R J BALASUBRAMANYAM

    2. Designation JTO CTTC Jammu

    3. Basic Pay + DA (as on 01-04-2017) 49369

    4. Place Of Duty CO J&K

    5. Name Of Patient R J BALASUBRAMANYAM

    6. Relationship with Employee SELF

    7. Age 031

    8. Nature Of Illness General

    9. Name Of Doctor/Hospital Dr Jagmeet Kour /

    10. Details Of Claim : Date of Claim Submission Jul 21, 2017

    (attach prescription, vouchers)

    Voucher Date Claim Type Voucher No. Amount


    May 30, 2017 Consultation 200.00

    Jun 12, 2017 Consultation 200.00

    Jun 28, 2017 Consultation 200.00

    Jul 12, 2017 Consultation 200.00

    May 30, 2017 Medicines 107 915.00

    Jun 12, 2017 Medicines 108 2400.00

    Jun 28, 2017 Medicines 109 1785.00

    Jul 12, 2017 Medicines 110 4442.00

    TOTAL 10342.00
    Medical Reimbursement Claim Form For Outdoor Treatment
    Annexure - C to ( Order Dt. 22 April 2003 )

    Claim Number 00000000000002023741 Personnel Number 01100413

    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 wholly dependent on me.

    (Signature of Employee)

    Mobile No. 9419120635

    You might also like