Medical Charges Reimbursement Form
Download a blank fillable Medical Charges Reimbursement Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical Charges Reimbursement Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2H.P.T.R.6
MEDICAL CHARGES REIMBURSEMENT FORM
1. Name and Designation
:…………………………………………………….
2. Office in which Employed
:…………………………………………………….
3. Basic Pay
:…………………………………………………….
4. Name of Patient & relation
with the Claimant
5. Period of Illness
:…………………………………………………..
6. PARTICULARS OF TREATMENT:
Item Names
Charges
Details of Cash-Memos etc.
(i) Medicines (Name)
(ii) Laboratory Tests/Ambulance/Consultancy/Indoor Room/Others (Specify)
6. Total Claim
Rs………………
7. Less- Advance Drawn vide T/V
No…………………. Dt……………..Rs……………………
8. Net Amount Payable
Rs……………………
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 the DDO
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business