Medical Reimbursement Claim Form For Outdoor Treatment

Annexure - C to ( Order Dt. 22 April 2003 )

Claim Number 00000000000002023741 Personnel Number 01100413

1. Name Of Employee R J BALASUBRAMANYAM

2. Designation JTO CTTC Jammu

3. Basic Pay + DA (as on 01-04-2017) 49369

4. Place Of Duty CO J&K

5. Name Of Patient R J BALASUBRAMANYAM

6. Relationship with Employee SELF

7. Age 031

8. Nature Of Illness General

9. Name Of Doctor/Hospital Dr Jagmeet Kour /

10. Details Of Claim : Date of Claim Submission Jul 21, 2017

(attach prescription, vouchers)

Voucher Date Claim Type Voucher No. Amount

May 30, 2017 Consultation 200.00

Jun 12, 2017 Consultation 200.00

Jun 28, 2017 Consultation 200.00

Jul 12, 2017 Consultation 200.00

May 30, 2017 Medicines 107 915.00

Jun 12, 2017 Medicines 108 2400.00

Jun 28, 2017 Medicines 109 1785.00

Jul 12, 2017 Medicines 110 4442.00

TOTAL 10342.00
 Medical Reimbursement Claim Form For Outdoor Treatment
Annexure - C to ( Order Dt. 22 April 2003 )

Claim Number 00000000000002023741 Personnel Number 01100413

Declaration : I hereby declare that the statements given in application are true to the best of my knowledge
and belief and that the person for which medical expenses are incurred is wholly dependent on me.

(Signature of Employee)

Mobile No. 9419120635