H.P.T.R.

Medical Charges Reimbursement Form

1. Name and Designation

SUNDER LAL, Cook Retd.

2. Office in which Employed

H.P.P.W.D. B& R (AE, Sub Division No. 1)

3. Basic Pay

6200/-

4. Name of Patient & Relation

Self

5. Period of Illness

19.09.13 to 30.11.13

6. Particulars of Treatment :

SN Item Names
30 Cap Ecosprin
30 Tab Telzy40
30 Cap Lynco I
30 Cap PD Star
30 Tab Boncal
30 Tab Mathacfa
30 Cap Ecosprin
30 Tab Telzy40
30 Cap Lynco I
30 Cap PD Star
30 Tab Boncal
30 Tab Mathacfa
1 Amp Emesct
1 Vail Panzel
2 Nos syninze 5 ml
30 Cap Ecosprin
30 Tab Telzy40
30 Cap Lynco I
30 Cap PD Star
30 Tab Boncal
30 Tab Mathacfa
30 Cap Evion - 600

Charges
Details of Cash- Memos etc.
62.40
196.50
Cash Memo no. 7535 dated
269.70
19.09.2013, Jhina Medical
216.00
Store Solan (H.P.)
264.00
297.00
Bill Total
1305.60
62.40
196.50
269.70
Cash Memo no. 9531 dated
216.00
30.10.13,
Jhina Medical Store
264.00
Solan (H.P.)
297.00
15.50
59.00
10.00
Bill Total
1390.10
62.40
208.50 Cash Memo no. 10462 dated
269.70 30.11.13, Jhina Medical Store
Solan (H.P.)
216.00
264.00
297.00
73.20
Bill Total
1390.80
Grand Total

7. Total Claim

4086.50

Rs. 4086 (Four Thousand Eighty Six Only)

8. Less Advance Drawn Vide T/V

No. _________ Drt._______
9. Net amount payable

Rs.
Rs. 4086 (Four Thousand Eighty Six Only)

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 claimant)

VERIFICATION CERTIFICATE
I Dr. __________________________ hereby certify that ______________________
Suffering from _________________________________ and is / was under my treatment
From _________________ to _________________ and that the above mentioned medicines
/tests were prescribed by me in this connection.
The claim is verified for Rs. ____________________

Date :_______________________

(Signature of Medical Officer)

Designation & Seal

-----------------------------------------------------------------------------------------------------------------------------Passed for Rs. ________________________ (Rupees )__________________________

_____________________ and included in Bill no. ________________ Dated ______________

(Signature of controlling Officer)

(Signature of the DDO)

--------------------------------------------------------------------------------------------------------------------------Instructions
1. List all the medicines, tests etc. individually
2. Attach Cash-Memos duly verified.
3. Mention dates of admission to the Hospital, stay etc.