Medical Reimbursement Claim for Outdoor treatment for the month of November13

of Sri Ashutosh Sarker, Sr. TOA (G) retired on 30/11/09 (A/N)

Diagnostics/ Tests:
Sl. No.
1
2
3
4
5
6
7
Total

Voucher No.
RH281226
RH291183
RH298587
RH298588
RH302186
BO/13/403174
07-OB-13-12621

Date
07/11/13
11/11/13
19/11/13
19/11/13
19/11/13
22/11/13
22/11/13

Amount
130.00
600.00
250.00
1100.00
6000.00
220.00
2200.00
10,500.00

Medicines/ Injections:
Sl. No.
8
9
Total

Voucher No.
826492
CA-5438

Date
26/11/13
28/11/13

Amount
100.00
177.50
277.50

Grand Total
10,777.50
(Rs. Ten Thousand Seven Hundred and Seventy
Seven and Fifty Paisa only )

(Signature of the
Employee)
Ashutosh Sarker, Ex. Sr.
TOA (G)
Retired on 30/11/09 (A/N)
Kalyani Cash Collection
O/o the Area Manager
(BKP)
Mob. No. 09433008489