MEDICAL EXPENSE REIMBURSEMENT

Name:

____________________________________________________ Department: _____________________________________

Employee # __________________________________________________ Grade: __________________________________________

Location: ____________________________________________________ _________________________________________________
Name of Doctor/Institution: ____________________________________ _________________________________________________

Medical Expenses Incurred by:

Myself

____________________________________________________

Spouse ____________________________________________________
Children ____________________________________________________
Parents ____________________________________________________

1.

Consultation Fee Rs. ___________________________________

2.

Lab charges Rs. ______________________________________

3.

Hospitalization Charges Rs. _____________________________

4.

Cost of Medicines Rs. __________________________________

5.

Others (Please Specify) ________________________________

Amount in words

Claimant's Signature: _________________________________________ Date: ___________________________________________

Verified by(HR Dept): _________________________________________ Date: ___________________________________________
Chief Executive: ______________________________________________

Date: __________________________________________