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Medical Reimbursement Application Form

The document is an online application form submitted by Ram Autar Singh, a head constable, to the Superintendent in Chief requesting medical reimbursement for his son Anuj Singh's treatment. It provides details about the treatment category, patient and employee information, expenditure bills totaling 38,252 rupees, and bank details for reimbursement.

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anuj thakur
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393 views1 page

Medical Reimbursement Application Form

The document is an online application form submitted by Ram Autar Singh, a head constable, to the Superintendent in Chief requesting medical reimbursement for his son Anuj Singh's treatment. It provides details about the treatment category, patient and employee information, expenditure bills totaling 38,252 rupees, and bank details for reimbursement.

Uploaded by

anuj thakur
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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Department of Medical Health and Family Welfare


Government of Uttar Pradesh

Online Application Form for Registration of Medical Reimbursement

To, Application Number : MER0020889


The Superintendent in Cheif / Chief Medical Superintendent,
Distt : Gautam Buddha Nagar
Uttar Pradesh
Sir,
Kindly Register my request for issuance of Medical Reimbursement which are given as below:

1 Treatment Type:

Treatment Category For Both Treatment

2 Employee's Detail:

Full Name Ram Autar Singh Father Name Sundar Singh

Designation Head Constable Aadhaar No. 541430047818

Date Of Birth 01/01/1970 Gender Male

Mobile No 9868030485

3 PPO detail:

Retired from Employeement No

4 Address of Current Posting :

Office Name police station Office Incharge Name sujeet updhyay

Address Beta - 2 Greater Noida State Uttar Pradesh

District Gautam Buddha Nagar Pincode 201301

5 Permanent Address :

Address Village - Bedamau Post - Dohrapur State Uttar Pradesh

District Kanpur Dehat Pincode 209115

6 Patient`s Details:

Requesting Medical Reimbursement Dependent Hospital Type Pvt


for

Patient Name Anuj Singh Age 14

Gender Male Disease Name Contracture of Thumb Left Hand

Place where Disease Identified Noida Hospital Name Neo Hospital

Doctor Name Dr. Paras Bhat Treatment Period From 11/12/2019

Treatment Period To 12/12/2019 Patient Aadhaar no 845639374687

Relations with Employee Son

7 Details of expenditure:

S.No. Bill Type Bill No. Date Amount Download

1 Medicine 00076410 11/12/2019 1038.00



2 Medicine 00080594 27/12/2019 345.00

3 Medicine 00076779 12/12/2019 2496.00

4 Medicine 00080273 26/12/2019 15.00

5 Consultation 00073706 10/12/2019 150.00

6 Investigation 00073910 11/12/2019 5000.00

7 Investigation 00074257 12/12/2019 12104.00

8 Hospital Bill 00006072 12/12/2019 17104.00

Total 38252.00

8 Advance Detail:

Have you already taken Advance No

9 Bank Details of Employee:

Bank Name STATE BANK OF INDIA Branch Name B BLOCK SECTOR -2 NOIDA

Account Number 10829601767 IFSC Code SBIN0005936

Date Place Signature of Person Incharge

Print Application Number : MER0020889 Department of Medical Health and Family Welfare Government of Uttar Pradesh Online Appl

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