OPD CLAIM FORM (TO BE FILLED BY EMPLOYEE) 1 2 3 4 5 6 7 INVOICE #: (i) (ii) (iii) TOTAL AMOUNT CLAIMED CHECKLIST: Use

e separate claim forms if bills are for more than one patients / persons . Please ensure to attach the following documents along with this claim form. (Please indicate by tick mark yourself) Sr# (i) (ii) (iii) (iv) DOCUMENTS Prescription of the doctor Original Invoices of the doctor & lab etc Computerized Pharmacy Invoices Copy of Investigations Reports YES NO If NO Then Describe the Reason NAME OF EMPLOYEE HEALTH CARD # NAME OF PATIENT (FOR WHICH CLAIM IS MADE) AGE RELATION WITH EMPLOYEE (encircle the right choice) PERIOD FOR WHICH CLAIM IS MADE (MONTH) Self Spouse Daughter Son

DETAILS OF AMOUNT CLAIMED

AMOUNT IN RS.

We, the undersigned, do hereby declare that, to the best of our knowledge and belief, the foregoing particulars are true and correct. We authorize the company to obtain information from Doctor/Hospital/Pharmacy/Lab concerning the treatment for which claim is made.

________________________ Employee's Signature with date FOR COMPANYS USE ONLY: CONSULTATION Rs. PHARMACY Rs. LABS Rs.

________________________ Department Head/Branch Managers Signature & Stamp

CLAIM DUE TO ANY REMARKS ANY DEDUCTION CLAIM PROCESSED BY:

DIAGNOSTICS Rs. DIAGNOSIS

DENTAL Rs.

OTHER (SPECIFY) Rs.

Rs.

AMOUNT APPROVED

Rs.

CLAIM APPROVED BY: